Case Report, Int J Cardiovasc Res Vol: 9 Issue: 6
An Experience of Performing Device Closure in Two Cases of Rupture of Sinus of Valsalva Aneurysm during the COVID-19 Pandemic
*Corresponding Author: Dr. Shishir Soni, MDSenior Resident, Department of Cardiology, All India Institute of Medical Sciences Rishikesh, Uttarakhand, Postal Address: 808, Building number 85, AIIMS campus, AIIMS Rishikesh, Veerbhadra Road, Rishikesh, Uttarakhand, 249201, India, Phone: (+91)9039266470 E-mail: [email protected]
Received: September 04, 2020 Accepted: September 24, 2020 Published: October 01, 2020
Citation: Kumar B, Soni S, Kodliwadmath A, Kumar A, Singh A (2020) An Experience of Performing Device Closure in Two Cases of Rupture of Sinus of Valsalva Aneurysm during the COVID-19 Pandemic. Int J Cardiovasc Res 9:6.
Device closure of the Rupture of Sinus of Valsalva (RSOV) has become a key management strategy over the last two decades whereas surgery has been limited to conditions where device closure is not a suitable option. Complex procedures such as device closure of the RSOV aneurysm is challenging during the COVID-19 pandemic. Despite the prevailing condition due to the COVID pandemic, patients with this RSOV can have poor prognosis over time if not treated timely and thus necessitates timely closure. RSOV device closure can be performed with a shorter procedural duration which is important during the COVID pandemic; by utilizing multimodality imaging especially involving Three-Dimensional Transesophageal Echocardiography (3D-TEE). We report two such cases of RSOV, which was successfully treated with device closure. One case was RSOV to the right ventricle in a 36-year man while the other was RSOV to the right atrium in a 32-year woman. Both these cases presented to us during the COVID-19 pandemic and had undergone percutaneous device closure of RSOV under fluoroscopy and 3D-TEE guidance.
Keywords: Rupture of sinus of valsalva aneurysm; Device closure; COVID-19 Pandemic
Rupture of sinus of valsalva aneurysm; Device closure; COVID-19 Pandemic
During COVID 19 pandemic, it is important to perform the procedure promptly. A complex procedure such as RSOV device closure can be performed in a relatively shorter duration with the help of multimodality imaging especially involving three-dimensional transesophageal echocardiography.
Performing device closure for the RSOV is not a new entity nowadays [1-3]. However, performing such a procedure during the current COVID-19 pandemic is a challenging task. Giving priority to urgent cath lab procedures has been the established strategy but in patients with RSOV, a poor outcome is inevitable if not treated with surgery or device closure . While performing this procedure our aim was not only to perform successful device closure but also to perform the procedure in a shorter duration of time without compromising the outcomes using a multimodality imaging approach involving 3D-TEE, transthoracic echocardiography, fluoroscopy, and cine-angiography. We report two cases of RSOV who underwent successful device closure in our institute during the COVID pandemic.
A 36 -year male with complaints of chest pain 7 months back associated with exertional palpitation and sudden onset breathlessness that gradually progressed over the last 7 months to New York Heart Association (NYHA) class III came in the emergency for evaluation and management. He has already undergone Coronary Angiography (CAG) and Transthoracic Echocardiography (TTE) 6 months back in a nearby hospital which revealed normal CAG and his TTE was suggestive of RSOV draining into the Right Ventricle (RV) for which cath study was performed and subsequently, device closure was advised. He did not turn up for further management due to the COVID pandemic until he developed worsening of symptoms including exertion palpitation and breathlessness. He was admitted from emergency and after his COVID testing, he was planned for device closure. Before the procedure, he was evaluated for suitable anatomy for device closure and presence of any other associated condition such as Aortic Regurgitation (AR) and Ventricular Septal Defect (VSD) using both TTE and Trans-Esophageal Echocardiography (TEE). Echocardiography revealed the size of RSOV of around 10 mm at the aortic end (9.8mm by TTE and 10.5 by 3D-TEE). The procedure was done under General Anesthesia (GA) with the help of TEE and fluoroscopy guidance through the right femoral route (Figure 1A-C). After getting venous and arterial access, an aortic root angiogram was done with the help of a 6F pigtail catheter which confirmed the findings. Quantification of the size of RSOV at the aortic end on angiogram suggested 9.5 mm, however, 3D-TEE estimation quantified the same at around 10.5 mm therefore device (PDA duct occluder) of size 14mm x 16mm was selected for closure. The RSOV was crossed with 0.035’’ Terumo wire (260 cm) from the aortic end (through right femoral artery) and snared out through the right femoral vein to form an arterio-venous loop with the help of snare. The delivery sheath was advanced from the venous end and the device was loaded onto the sheath and was delivered across the RSOV (Figure 1B,1C). The device was released after confirmation of the position by TEE and fluoroscopy. The patient was extubated and kept under observation for 2 days followed by discharge after an uneventful in-hospital course.
Figure 1: Panel A-C showing ruptured sinus of Valsalva draining into the right ventricle near the pulmonary valve imaged in three-dimensional transesophageal echocardiography - short axis view at the level of aortic valve (A), the advancement of the sheath and crossing across RSOV connection imaged in Fluoroscopy (B), Device (Duct occluder) position in fluoroscopy (C).
A 32-year female presented to the emergency department with 2 months of breathlessness, reduced appetite, and lower limb swelling preceded by an episode of chest pain. She had been admitted 1 month back for these complaints in some other hospital where she was worked up and diagnosed as a case of RSOV draining into the right atrium (RA) for which she was advised for device closure. The patient was admitted and after COVID-19 testing, and further workup including echocardiography, she was taken up for device closure. The procedure was performed under GA with TEE and fluoroscopy guidance through the right femoral route. The Aortic root angiogram suggested RSOV draining into RA from the noncoronary sinus (Figure 2A). The size estimation on angiogram and 3D-TEE quantified the size of RSOV at the aortic end of 10.8 mm and 11.2 mm respectively. Therefore, the device (PDA duct occluder) of size 14mm x 16mm was selected and was successfully delivered under TEE and fluoroscopy guidance (Figure 2B-D). The patient was extubated and observed for 2 days and was discharged subsequently on day 3 of the procedure.
Figure 2: Panel A-D showing aortic root injection through pigtail catheter resulting in the passage of contrast from the non-coronary sinus of aorta to the right atrium in AP projection on fluoroscopy (A), Snaring of the wire in SVC advanced through aortic end across RSOV (B), Device (Duct occluder) position in fluoroscopy image (C), Aortic retention disc device (duct occluder) in the non-coronary sinus of aorta imaged in three-dimensional transesophageal echocardiography (D).
The RSOV is a condition due to developmental defects at the junction of aortic media and annulus fibrosus leading to aneurysm formation and rupture [3,4]. It may be associated with congenital aneurysms of sinus of Valsalva or acquired due to infective endocarditis, or rarely in association with Behcet disease or as a long term complication following repair of aortic dissection . It can rupture into any chamber however it commonly ruptures into RV and RA and rarely into the pulmonary artery, Left Ventricle (LV), left atrium, or pericardial cavity. Mostly a patient with RSOV presents with an episode of severe chest pain followed by symptoms of the volume overload, which requires prompt management otherwise symptoms of heart failure and worst outcomes are inevitable in less than a year in most of the cases  However, variability in the presentation exists depending on the site of rupture. According to the Sakakibara and Konno’s classification of aneurysms of sinus of Valsalva, it is grouped into four types namely type 1 (right sinus, RV near pulmonary valve), type 2 (mid-portion of right sinus, RV), type 3 (mid-portion of right sinus, RA/RV towards tricuspid valve) and type 4 (non-coronary sinus, RA ) based on site of rupture (aortic sinus) and draining chamber. Case 1 and case 2 belong to type 1 and type 4 respectively (Figures 1 and 2). Both the patients were already on diuretics (Torsemide) which was started at the time of presentation to other hospitals and were referred for the device closure. Previously surgery was the mainstay of treatment which is now preferred in the condition of unsuitable anatomy, rupture into LV or PA, aneurysmal opening within 5mm of coronary Ostia, associated VSD and AR, LV dysfunction, and in the condition of systemic desaturation, right to left shunt with increased pulmonary vascular resistance [3,7]. Thus the selection of the patient for device closure is most important. In our cases, both had suitable anatomy for device closure. For RSOV device closure, duct occluder is usually preferred, however, the VSD closure device has been reported to be used in some case reports . When duct occluder is selected then the suitable size of the device is usually 2-4 mm higher than the size of the RSOV at the aortic end [8,9]. A larger device can interfere with the movement of aortic valve cusp or impede coronary blood flow while a suboptimal device size may lead to residual shunt or increased risk of device embolization . Therefore, precise estimation of the size of the RSOV at the aortic end is important which can be quantified by TTE, TEE, 3D-TEE, and on aortic root angiogram. In these two cases, we preferred 3D-TEE estimation over other modality, however the difference less than 1 mm when measured by other methods (TTE and aortic root angiogram). Another advantage of 3D-TEE was observed during deployment of the aortic retention disc of the device as the tissue margins can be more clearly seen with 3D-TEE although the device was visible in both fluoroscopy and 3D-TEE . This helped in performing both the procedures timely with total fluoroscopy time less than 20 minutes which is much lesser than other reported studies [1,10]. These two procedures were performed during the COVID-19 pandemic when the spread of nosocomial infection (SARS COV 2) is another priority while performing any intervention . Although this patient was COVID-negative as detected by Reverse Transcriptase-Polymerase Chain Reaction (RT-PCR) technique, however with limited data on sensitivity and specificity of COVID testing and risk of acquiring the disease after hospitalization and risk of getting an infection from asymptomatic healthcare worker cannot be neglected and therefore timely done procedure with limited radiation exposure was an added advantage of this successful procedure involving multimodality imaging especially 3D-TEE.
- Sinha SC, Sujatha V, Mahapatro AK (2015) Percutaneous transcatheter closure of ruptured sinus of valsalva aneurysm: immediate result and long-term follow-up. Int J Angiol. 24: 99-104.
- Mahimarangaiah J, Chandra S, Subramanian A, Srinivasa KH, Usha MK, et al. (2016) Transcatheter closure of ruptured sinus of valsalva: different techniques and mid-term follow-up. Catheter Cardiovasc Interv 87: 516-522.
- Diwakar A, Patnaik SS, Hiremath CS, Chalam KS, Dash P, et al. (2019) Rupture of sinus of valsalva - A 15 years single institutional retrospective review: Preoperative heart failure has an impact on post operative outcome?. Ann Card Anaesth 22: 24-29.
- Ugurlucan M, Yildiz Y, Guler E, Ulukan MO, Oztas DM, et al. (2020) Giant aneurysm of the non-coronary sinus of valsalva. Braz J Cardiovasc Surg 35: 589-590.
- Shah RP, Ding ZP, Ng AS, Quek SS (2001) A ten-year review of ruptured sinus of valsalva: clinico-pathological and echo-doppler features. Singapore Med J 42: 473-476.
- Sakakibara S, Konno S (1962) Congenital aneurysm of the sinus of valsalva. anatomy and classification. Am Heart J 63: 405-424.
- Kerkar PG (2009) Ruptured sinus of valsalva aneurysm: yet another hole to plug!. Ann Pediatr Cardiol 2: 83-84.
- Tang L, Zhou SH, Fang ZF (2019) Transcatheter closure of ruptured sinus of valsalva aneurysm with double-disc perimembranous vsd occluder in man with mechanical aortic valve. Tex Heart Inst J 46: 211-214.
- Naeim HA, Khedr L, Mahmoud A, Saeed W, Taha EA, et al. (2019) Percutaneous closure of ruptured noncoronary sinus of Valsalva to right atrium causing severe right heart failure, a case report. J Cardiol Cases 21: 71-74.
- Jain PK, Narula J, Hasija S, Kiran U (2015) Is it really ruptured sinus of valsalva? The crucial role of comprehensive transesophageal echocardiography in clinical decision-making. Ann Card Anaesth 18: 221-224.
- Ganatra S, Dani SS, Shah S, Asnani A, Neilan TG, et al. (2020) Management of cardiovascular disease during coronavirus disease (COVID-19) pandemic. Trends Cardiovasc Med 30: 315-325.