Percutaneous Closure of Recurrent Noncoronary Sinus of Valsalva Aneurysm Rupture: Utility of Computed Tomography in Procedural P

Percutaneous Closure of Recurrent Noncoronary Sinus of Valsalva Aneurysm Rupture: Utility of Computed Tomography in Procedural Planning

   ABSTRACT: This case demonstrates the benefit of CT angiography in procedure planning and device selection for percutaneous closure of Sinus of Valsalva aneurysm rupture. As there is no dedicated equipment for closure, appropriate device selection is paramount. Amplatzer Muscular VSD Occluder device was chosen based on the anatomy of the defect that was readily appreciable by CT angiography, but was not well visualized with transesophageal echocardiography and thoracic aortography. CT angiography can provide anatomic information vital to percutaneous procedure planning and device selection. It is complementary to other imaging modalities.

J INVASIVE CARDIOL 2010;22:336–338

Key words: CT angiography, VSD occluder device    Sinus of Valsalva aneurysm (SVA) is a rare defect that can be complicated by rupture into the adjacent cardiac chambers. It can be congenital or acquired due to syphilis, atherosclerosis, endocarditis, trauma from debridement during aortic valve replacement or a jet from a malpositioned valve.^1,2 The congenital form has a predilection towards people of Asian descent³ and can occur in isolation or associated with other malformations. Transesophageal echocardiography (TEE) and thoracic aortography are traditionally used for diagnosis and procedure planning. We present a case of percutaneous repair of recurrent SVA rupture with an Amplatzer^® Muscular VSD Occluder (MVSDO) (AGA Medical Corp., Plymouth, Minnesota) illustrating incremental benefit of CT angiogram use for procedure planning and device selection.    Case report. A 28-year-old Laotian male underwent bovine pericardial patch repair of noncoronary SVA rupture into the right atrium 4 years ago. He was now found to have shortness of breath and a new murmur. Thoracic aortography showed faint left-to-right contrast shunting into the right atrium across a defect in the noncoronary SV. TEE with color flow Doppler showed a high velocity jet in the right atrium. However, neither study provided detailed visualization of the length of the fistulous communication or its spacial relationship to tricuspid and aortic valves (Figure 1). A cardiac CTA was performed, which allowed for detailed three-dimensional analysis of the recurrent rupture site. The CTA demonstrated an aneurysm measuring up to 7 mm x 8 mm x 4 mm in maximal diameters with tapering inferiorly to 3 mm towards the right atrial aspect. Two main linear jets of contrast-enhanced blood were extending from the noncoronary aortic sinus into the right atrium immediately adjacent and superior to the septal leaflet of the tricuspid valve (Figure 2). The outer margin of the aneurysm was located 6 mm from the peripheral junction of the noncoronary and left coronary aortic valve leaflets, and 10 mm from the tricuspid valve annulus. The right atrial os of the defect measured 2.39 mm by subsequent intraprocedural TEE.    Percutaneous closure was performed under general anesthesia with fluoroscopic and TEE guidance. After performing thoracic aortography with a multipurpose diagnostic catheter, an angled exchange Terumo^® guidewire (Terumo Medical Corp., Somerset, New Jersey) was advanced through the fistulous tract into the right atrium, snared with a Microvena 50 mm snare (Microvena, White Bear Lake, Minnesota), and externalized at the right femoral vein. A 4 mm Amplatzer^® MVSDO was positioned in the ascending aorta via a 6 French Terumo^® sheath and deployed with both fluoroscopic and TEE confirmation. Immediate post-procedure thoracic aortography, TEE and a 2-month follow-up cardiac CTA (Figure 3) revealed a minimal residual shunt, which was expected to close. The patient tolerated the procedure well and has been asymptomatic since. Discussion    The prevalence of SVA is less than 1% in patients undergoing cardiac surgery.^1,6 Rupture of the weak point at the junction between the aortic media and annulus can be asymptomatic or result in hemodynamic embarrassment.¹ Early, aggressive treatment is recommended⁴ and surgical repair has traditionally been the treatment of choice. Surgical repair carries the potential for in-hospital mortality of 1.5–3.9%, with a 1.6% risk of stroke and a 1.6% rate of recurrence^4,6 and may be associated with an increased risk of aortic insufficiency postoperatively.⁵ Several cases of percutaneous closure have been successfully performed with the Rashkind umbrella,⁷ Gianturco coil,³ Amplatzer^® septal occluder,⁸ Amplatzer^® duct occluder,³ and Amplatzer^® muscular VSD occluder. Percutaneous closure was especially desirable in our patient, who had undergone previous open-heart surgery.    A thorough evaluation of defect anatomy is required for a safe and successful percutaneous closure. CTA was indispensable in preprocedural planning and steered device selection in our case. It provided reliable three-dimensional measurement of the fistulous defect itself and distances to the nearby structures, including aortic valve commissures and the tricuspid valve. There is currently no equipment dedicated to specifically address SVA rupture. Therefore, occluder choice is limited to devices available for other purposes and is predicated on accurate and detailed knowledge of defect anatomy. In our case, CTA demonstrated an elongated channel with ostia in close proximity to the aortic and tricuspid valves, a relationship not readily seen on TEE or thoracic aortography. MVSDO was thus particularly well-suited for use due to its relatively long waist length of 7 mm and low profile, with a difference between the waist and disk diameters of only 8 mm.⁹ This allowed the device to be accurately positioned within the length of the fistulous aneurysmal sac, as close as 4 mm from vital structures, without impinging on them. The choice of device size was guided by the narrowest diameter of the channel on the right atrial side, as precisely measured by CTA and confirmed by intraprocedural TEE.    Detailed anatomic information provided by the CTA was complementary to intraprocedural TEE and fluoroscopy and indispensable for appropriate device selection. ECG-gated CTA allows detailed visualization of cardiac anatomy and function¹⁰ and thus is an essential tool for preprocedural planning. From the Departments of *Medicine and §Radiology, Christiana Care Health System, Newark, Delaware. The authors report no conflicts of interest regarding the content herein. Manuscript submitted January 15, 2010, provisional acceptance given February 1, 2010, final version accepted February 8, 2010. Address for correspondence: Leonid Mandel, MD, Christiana Care Health System, Section of Cardiology, 4755 Ogletown-Stanton Road, Newark, DE 19718. E-mail: Leonid Mandel References

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