Abstract
We report a case of a Perforated Sinus of Valsalva Aneurysm (PSOV) closure using an Amplatzer muscular ventricular septal defect occluder (mVSD) device and describe a novel and potentially safer way for defect sizing. A literature review of the endovascular treatment of this disease is presented.
1
Introduction
Closure of a perforated sinus of Valsalva aneurysm has been traditionally performed by surgical approach and cardiopulmonary bypass. Recently, few reports with intermediate term follow up indicate that a less invasive percutaneous approach can be offered to these patients with satisfactory results. The type of device appropriate for this purpose has not been established and sizing of the defect poses some challenges due to the intrinsic weakness of the perforated aortic wall.
2
Case report
The patient is a 43-year-old Asian man who presented with a heart murmur, decreased exercise tolerance and palpitation over the past 6 months. His physical exam revealed a continuous murmur best heard on the left lower sternal border with normal P2 intensity, no precordial hyperactivity and normal pulse pressure.
Echocardiography and TEE revealed the presence of a perforated non coronary (NC) cusp sinus of Valsalva aneurysm (wind sock appearance) into the right atrium ( Fig. 1 ) with significant left to right shunt. The distance from the septal leaflet of the tricuspid valve from the defect was measured to be 1.3 cm. Right and left heart catheterization revealed QP/QS ratio of 2.4 and pulmonary systolic pressure of 32 mmHg. An aortogram showed the left to right shunt from the non-coronary cusp of the aorta into the right atrium; the RCA ostium was 1.5 cm distant from the aneurysm ( Fig. 2 ).
2.1
Procedure
The procedure was carried out under general anesthesia and endotracheal intubation with TEE guidance. A 6 Fr sheath was placed into the left common femoral artery and an 8 Fr long sheath into the left common femoral vein.
Following the administration of 7000 UI of unfractionated heparin, the perforation was crossed from the aortic side with a 6 Fr multipurpose (MP) catheter with the help of an angled stiff Terumo guide wire (Terumo, Elkton, MD). After looping the guidewire into RV apex it was redirected retrograde back into the right atrium and down to the IVC followed by the MP catheter. In order to overcome difficulties in advancing the MP catheter through the right atrium and down into the IVC a 5 Fr angled tip glide catheter was inserted coaxially into the MP catheter. The Terumo wire was then exchanged with a Bentson 0.035 inch guidewire successfully snared out from the left common femoral vein using a 10 mm goose neck snare (Cook incorporated, Bloomington, IN) to form an arterial venous loop.
Over this wire, from the venous side, a 24 mm Amplatzer sizing balloon was advanced and positioned with the distal half into the ascending aorta and the proximal half into the RA. Because of the differential pressure between the aorta and RA, we gently (1–2 atm) inflated the balloon just enough to cause its expansion into the RA; by a more gradual and steady inflation we inflated the segment of the balloon inside the perforation tract enough to create occlusion of the fistula confirmed by TEE color flow and repeat angiogram. At that point the segment of the balloon inside the fistula would take an isosceles triangular shape with its vertex toward the aorta and the base at the exit of the perforation into the RA. We measured the base of this balloon formed triangle as the diameter of the defect at the atrial side and the height of the triangle as the length of the perforation ( Figs. 3 and 4 ). We intentionally kept the distal balloon within the aorta collapsed to prevent overstretching.
The defect diameter, as obtained by balloon sizing, was 6.5 mm, slightly larger than the TEE (6.0 mm) and angiographically determined diameter (5.5 mm) at the same location. Its length was measured to be 9 mm.
After removal of the sizing balloon, an Amplatzer 7 Fr delivery sheath was advanced into the ascending aorta from the venous side. An Amplatzer 8 mm mVSD Occluder (AGA Medical Corp, Golden Valley, MN) was initially selected and deployed. While the device was still attached to the delivery cable a repeat aortic angiogram and TEE color flow imaging were obtained confirming the presence of significant high jet residual shunt. The 8 mm mVSD device was then recaptured by advancing the delivery sheath into the aorta. A 10 mm mVSD occluder was selected, brought in position and deployed.
Post implant repeat aortogram revealed a non-significant foamy-like residual shunt into the RA ( Fig. 5 ) without any high velocity jet confirmed by TEE ( Fig. 6 ). No interference with the aortic and tricuspid valve function was documented by TEE. At 6-month follow up transthoracic echocardiography revealed only trivial residual shunt with no tricuspid or aortic valve dysfunction or sign of perforation. The patient symptoms completely resolved.
2
Case report
The patient is a 43-year-old Asian man who presented with a heart murmur, decreased exercise tolerance and palpitation over the past 6 months. His physical exam revealed a continuous murmur best heard on the left lower sternal border with normal P2 intensity, no precordial hyperactivity and normal pulse pressure.
Echocardiography and TEE revealed the presence of a perforated non coronary (NC) cusp sinus of Valsalva aneurysm (wind sock appearance) into the right atrium ( Fig. 1 ) with significant left to right shunt. The distance from the septal leaflet of the tricuspid valve from the defect was measured to be 1.3 cm. Right and left heart catheterization revealed QP/QS ratio of 2.4 and pulmonary systolic pressure of 32 mmHg. An aortogram showed the left to right shunt from the non-coronary cusp of the aorta into the right atrium; the RCA ostium was 1.5 cm distant from the aneurysm ( Fig. 2 ).
2.1
Procedure
The procedure was carried out under general anesthesia and endotracheal intubation with TEE guidance. A 6 Fr sheath was placed into the left common femoral artery and an 8 Fr long sheath into the left common femoral vein.
Following the administration of 7000 UI of unfractionated heparin, the perforation was crossed from the aortic side with a 6 Fr multipurpose (MP) catheter with the help of an angled stiff Terumo guide wire (Terumo, Elkton, MD). After looping the guidewire into RV apex it was redirected retrograde back into the right atrium and down to the IVC followed by the MP catheter. In order to overcome difficulties in advancing the MP catheter through the right atrium and down into the IVC a 5 Fr angled tip glide catheter was inserted coaxially into the MP catheter. The Terumo wire was then exchanged with a Bentson 0.035 inch guidewire successfully snared out from the left common femoral vein using a 10 mm goose neck snare (Cook incorporated, Bloomington, IN) to form an arterial venous loop.
Over this wire, from the venous side, a 24 mm Amplatzer sizing balloon was advanced and positioned with the distal half into the ascending aorta and the proximal half into the RA. Because of the differential pressure between the aorta and RA, we gently (1–2 atm) inflated the balloon just enough to cause its expansion into the RA; by a more gradual and steady inflation we inflated the segment of the balloon inside the perforation tract enough to create occlusion of the fistula confirmed by TEE color flow and repeat angiogram. At that point the segment of the balloon inside the fistula would take an isosceles triangular shape with its vertex toward the aorta and the base at the exit of the perforation into the RA. We measured the base of this balloon formed triangle as the diameter of the defect at the atrial side and the height of the triangle as the length of the perforation ( Figs. 3 and 4 ). We intentionally kept the distal balloon within the aorta collapsed to prevent overstretching.
