Retrograde Approach for Closure of Ruptured Sinus of Valsalva

   ABSTRACT: Though ruptured sinuses of Valsalva have been traditionally managed surgically, they are amenable to transcatheter closure.¹ Various devices have been used for closure of these defects. We describe a novel technique of closure of a ruptured right sinus of Valsalva into the right ventricular outflow tract. A muscular ventricular septal defect occluder was deployed retrogradely, without resorting to the usual antegrade technique involving formation of an arteriovenous loop.

J INVASIVE CARDIOL 2010;22:343–345

Key words: ruptured sinus of Valsalva, retrograde transcatheter approach    Case Description. A 37-year-old male presented with complaints of worsening dyspnea (New York Heart Association II to IV) over the previous 3 months. Transthoracic echocardiography showed a ruptured right sinus of Valsalva (RSOV) into the right ventricular outflow tract (RVOT) and a small, restrictive perimembranous ventricular septal defect (VSD). The aneurysm measured 5 mm at the aortic end. There was no aortic regurgitation and no evidence of infective endocarditis.    We decided to close the RSOV using a patent ductus arteriosus occluder.² Aortography was performed to confirm the echocardiographic findings. The RSOV was crossed from the aortic side, and after formation of an arteriovenous loop, an 8 x 10 mm Lifetech Patent Ductus Arteriosus Occluder (Lifetech Scientific Co., Ltd, Schenzen, China) was delivered after confirming its position on fluoroscopy. The device embolized into the descending aorta soon after deployment and was retrieved using a Goose Neck snare (Boston Scientific, Natick, Massachusetts). The embolization of the duct occluder probably resulted from a technical flaw during device deployment with displacement of the device just prior to final release of the duct occluder. Though the duct occluder has a retention disc on the aortic side to prevent embolization, the margins of the ruptured sinus of Valsalva are very thin. The pressure gradient between the aorta and RVOT, which would normally prevent embolization of the device, may not help in the instance of the device being malaligned at the time of release. Any displacement would expose the RVOT side of the aortic retention disc to systemic pressures and nullify the gradient between the two sides of the device, which is crucial to holding the device in place. The thin margins of the RSOV may not have provided adequate support for the duct occluder, which has a retention skirt only on the aortic side.    We then attempted closure using a muscular VSD intracardiac patch occluder a few days later. The procedure was performed under transesophageal echocardiographic (TEE) guidance. After an aortogram was obtained, a 6 Fr JR (Cordis Corp., Miami Lakes, Florida) catheter was passed in the RVOT across the RSOV using a hydrophilic guidewire (Terumo Corp., Tokyo, Japan). This was then exchanged over a 0.038 inch x 260 cm Extra-Stiff guidewire (Cook, Inc., Bloomington, Indiana) for a 9 Fr Mullins sheath (Cook). The floppy end of the extra-stiff wire was delivered across the defect into the right ventricle. The 9 Fr Mullins sheath was then passed over the wire into the defect. This was accomplished quickly and the wire withdrawn once the sheath had crossed the defect. A 7 mm muscular VSD Intracardiac Patch Occluder (Lifetech Scientific Co., Ltd, Schenzen, China) with the delivery system was then introduced through the sheath. The disc on the RVOT side was initially released, and after confirming its position on TEE and fluoroscopy, the aortic end was delivered by withdrawing the sheath further. Prior to final release of the device, its position was confirmed on angiography. There was no residual shunt across the RSOV after device deployment. Left ventriculography confirmed the presence of a small perimembranous VSD.    Adequate hemostasis was achieved at the 9 Fr arteriotomy site with firm manual compression for 20 minutes. There were no access-site complications on follow up.    Our patient has been on follow up for the last 4 months. There is no residual shunt or aortic regurgitation. Though there are no recommendations regarding the use of antiplatelet agents, we have started him on aspirin to protect against the rare occurrence of a thromboembolic event. Discussion    The sinuses of Valsalva are three small dilatations in the wall of the aorta, immediately above the attachments of each aortic cusp. Rupture of these sinuses can manifest as sudden cardiac death, congestive cardiac failure or arrhythmias.^3,4 Closure of these defects is increasingly being performed by interventional cardiologists. Transcatheter closure of a ruptured aneurysm of a sinus of Valsalva was first performed by Cullen et al in 1994 using a Rashkind Umbrella Device.⁵    A retrograde approach for closure of a RSOV has not been previously described. Fluoroscopic time is considerably less compared to the conventional antegrade approach since it eliminates the need for formation of an arteriovenous loop. It also minimizes the use of hardware. Arterial access through both femoral arteries is necessary, one side for introducing the pigtail to obtain angiograms, and the other side for device deployment.    The muscular VSD Intracardiac Patch Occluder is suited for this approach since it has discs at both ends and can be deployed from the arterial side. The muscular VSD Occluder (Lifetech Sci Company) is made of ceramic coated nitinol, woven in to a mesh. It also incorporates an expanded polytetrafluroethylene (e-PTFE) flow-resistant membrane that reduces residual shunts and speeds endothelialization. It has a 7 mm connecting waist (corresponding to the thickness of the muscular ventricular septum) and two retention discs at either end. The waist diameter can vary from 4 mm to 16 mm. We used a device with a waist diameter of 7 mm. The retention skirts on either side of this device measured 13 mm.    The patent ductus arteriosus (PDA) occluder is a percutaneous transcatheter occluding device for the non-surgical closure of PDA defects, and has also been employed for closure of ruptured sinuses of Valsalva. The device consists of a knitted nitinol wire mesh, which is heat-set to expand to a T shape. An e-PTFE membrane is sewn inside the disc with nylon thread on the aortic side, and two e-PTFE membrane is sewn inside the disc with nylon thread on the aortic side, and two e-PTFE membranes are sewn inside the waist to facilitate faster closure of the shunt by blocking blood flow.    Though both these devices have been used for closure of RSOV, the VSD occluder may provide additional stability due to retention discs at both ends. Unlike the duct occluder which needs to be deployed only from the RVOT side, the VSD occluder can also be deployed from the aortic end of a ruptured sinus of Valsalva. Ruptured sinuses of Valsalva have been managed non-surgically with various ductal and septal occluders with follow up for late embolization of the device.^2,6,7 We have earlier closed ruptured sinuses of Valsalva at our institution using the antegrade technique for device deployment with no late embolization. Although the follow-up period in this case is still insufficient to comment on the risk of late embolization, we do not believe an alternative approach used here for deployment of the device would add to the risk. Conclusion    Ruptured aneurysms of sinuses of Valsalva can be managed non-surgically. The technique described here, though not previously used, is both safe and quicker than the conventional antegrade approach. From the Departments of Cardiology and *Pediatric Cardiology, Sri Jayadeva Institute of Cardiovascular Sciences and Research, Bangalore, India. The authors report no conflicts of interest regarding the content herein. Manuscript submitted November 5, 2009, provisional acceptance given November 25, 2009, final version accepted February 22, 2010. Address for correspondence: M. Jayaranganath MD, DM, Sri Jayadeva Institute of Cardiovascular Sciences and Research, Bannerghatta Road, Bangalore, India – 560 069. E-mail: jayranganath@yahoo.com References

1. Kerkar PG. Ruptured sinus of Valsalva aneurysm: Yet another hole to plug! Ann Pediatr Card 2009;2:83–84 2. Arora R, Trehan V, Mahesh U, et al. Transcatheter closure of ruptured sinus of Valsalva aneurysm. J Intervent Cardiol 2004;17:53–58. 3. Sakakibara S, Konno S. Congenital aneurysm of the sinus of Valsalva. Anatomy and classification. Am Heart J 1962;63:405–424. 4. Perloff JK. The Clinical Recognition of Congenital Heart Disease, 5th edition, Saunders, Elsevier Science. 2003, pp. 457–470. 5. Cullen S, Somerville J, Redington A. Transcatheter closure of ruptured aneurysm of sinus of Valsalva. Br Heart J 1994;71:479–480. 6. Cullen S, Vogel M, Deanfield JE, et al. Rupture of aneurysm of the right sinus of Valsalva into the right ventricular outflow tract: Treatment with Amplatzer atrial septal occluder. Circulation 2002;105:E1–E2. 7. Bijulal S, Harikrishnan S, Ajitkumar VA. Nonsurgical closure of recurrent rupture of sinus of Valsalva aneurysm in the presence of aortic prosthesis. J Invasive Cardiol 2009;21:E42–E43.