Br HeartJ 1994;71:479-480

TECHNIQUE

Transcatheter closure of a ruptured aneurysm ofthe sinus of Valsalva

Seamus Cullen, Jane Somerville, Andrew Redington

AbstractA ruptured aneurysm of the sinus ofValsalva in a man of 34 was closed by atranscatheter technique with a 12 mmmodified Rashkind umbrella device.

(Br HeartJ 1994;71:479-480)

Rupture of an aneurysm of the sinus ofValsalva is rare and is more likely to occur inadolescence or adult life.' It is usually causedby a congenital weakness of the wall of thesinus which leads to progressive dilatation andultimately rupture into one of the four cham-bers of the heart or into the mediastinum.

Cross sectional echocardiography can accu-rately demonstrate the defect, which can becorrected surgically without recourse to car-diac catheterisation.2 After a successful cor-rection the long-term prognosis is usuallygood, though aortic regurgitation and recur-rence of lesions have been reported.We describe successful transcatheter clo-

sure of a ruptured sinus of Valsalva.

Royal BromptonNational Heart andLung Hospital,LondonS CullenJ SomervilleA RedingtonCorrespondence to:Dr Andrew Redington,Royal Brompton NationalHeart and Lung Hospital,Sydney Street, LondonSW3 6NP.

Case reportA 34 year old man was referred to this hospitalwith a three month history of increasingbreathlessness on exertion and of fatigue. Tenyears before he had had surgery elsewhere for a

ruptured aneurysm of the sinus of Valsalva.He had been symptom free with no murmursuntil this presentation. He had a grade 4/6continuous murmur best heard at the mid-sternal edge. A standard 12 lead electrocar-diogram showed sinus rhythm, left atrialenlargement, and left ventricular hypertrophy.Cross sectional echocardiography showed theusual atrial arrangement (situs solitus), con-

cordant connections, and a left-sided aorticarch. The aortic root was dilated (4 7 cm).Colour Doppler examination showed a highvelocity jet originating from the right coronarysinus and entering the right ventricle. There

was trivial aortic incompetence. Cardiaccatheterisation was performed under generalanaesthesia. The pulmonary artery pressurewas normal but there was a pulmonary to sys-temic shunt (2:1) with a step up in oxygensaturation in the right ventricular outflowtract. An aortogram showed contrast passingfreely from the right coronary sinus into theright ventricle and filling the right ventricularoutflow tract (figure).

PROCEDUREBoth femoral arteries were entered percuta-neously with 7 French introducers. The rightfemoral vein was entered with an 8 Frenchintroducer. Heparin (100 units/kg) was givenduring the procedure and one dose of flu-cloxacillin and gentamicin was given. The fis-tula was shown by aortography and the rightventricle was entered retrogradely from theaorta with a 7 French multi-purpose end holecatheter. This was exchanged for an 0-035inch guidewire over which an 8 FrenchMullins transseptal sheath was advanced intothe right ventricle. A 12 mm modifiedumbrella device3 was passed through thesheath and deployed with ease, avoiding thecoronary ostia. Positioning of the device wasassisted by repeated injections of contrastmedium into the aortic root via the catheteradvanced from the contralateral leg. The finalaortogram showed a trivial leak across thedevice and no aortic regurgitation (figure).The procedure took 57 minutes and no mur-murs were audible after the device was in place.

Repeat cross sectional echocardiographythe next day showed trivial aortic regurgita-tion and no leak across the device. Thepatient was discharged from hospital. He wassymptom free six months later. We recom-mended a short period of anticoagulation andadvised life-long antibiotic prophylaxis.

DiscussionAlthough the Rashkind umbrella wasdesigned to close the arterial duct,4 we andothers have used it to close atrial and ventricu-lar septal defects and major aorto-pulmonarycollateral arteries.35 Hourihan et al used thedevice to prevent valvar and paravalvar leaks.6

Rupture of the sinus of Valsalva is a rarelesion and in patients with symptoms it mustbe surgically closed during cardiopulmonarybypass. The long-term results of successfuloperation are usually good but aortic regurgi-tation can develop or the lesion can recur. Wepresume that a recurrence explains the newpresentation in our patient. Repeat ster-notomy was clearly undesirable and in view ofthe apparently ideal position of the defect, wedecided to attempt closure with a trans-catheter umbrella. Transcatheter closure ofthis lesion has not been described before,although Lock's group reported successfulanterograde transcatheter closure of an aorta-to-right-ventricular fistula after aortic valve

479 on D

ecember 7, 2020 by guest. P

rotected by copyright.http://heart.bm

j.com/

Br H

eart J: first published as 10.1136/hrt.71.5.479 on 1 May 1994. D

ownloaded from

Cullen, Somerville, Redington

Left anterior oblique (A) and lateral (B) views of aortogram showing a fistula between right coronary sinus and rightventricle. Left anterior oblique (C) and lateral (D) views of repeat aortogram with umbrella device in place showing noresidual defect.

replacement.6 In their patient closure wascomplicated and was successful after threeattempts. The patient was clinically well 32months after the final intervention. He was inNYHA congestive heart failure class 1. Theypreferred an anterograde venous approachand snared a wire passed retrogradely throughthe defect. We think that this may unnecessar-ily complicate the procedure. A retrogradearterial approach, as used in our patient, facil-itates accurate placement of the umbrelladevice and should significantly shorten theprocedure time. This approach should at leastbe considered in future cases.We and others have emphasised the bene-

fits of transoesophageal echocardiography fortranscatheter closure of intrtacardiac lesions.However, in our patient single plane trans-oesophageal echocardiography did not help usto position the device. Longitudinal scanningmay have been more useful but was not avail-able at the time of study. We decided to placea second catheter in the aortic root via thecontralateral femoral artery, through whichwe repeatedly injected small amounts of con-trast material to outline the defect during

deployment of the device. The long-term riskof infective endocarditis is unknown, it seemsprudent, however, to advise life-long anti-biotic prophylaxis in patients with devices inthis position. Because the device may be asource of systemic emboli we advise short-term anticoagulation during the period ofendothelialisation.

This instance of successful transcatheterclosure of a ruptured sinus of Valsalvaaneurysm extends the indications for use ofthe umbrella device.

1 Goldberg N, Krasnon N. Sinus of Valsalva aneurysms.Clin Cardiol 1990;13:831-6.

2 Sahasakul Y, Panchavinnin P, Chaitharaphan S, SakiyalakP. Echocardiographic diagnosis of a ruptured sinus ofValsalva:operation without catheterisation in sevenpatients. Br HeartJ 1990;64:195-8.

3 Redington AN, Rigby ML. Novel uses of the Rashkindductal umbrella in adults and children with congenitalheart disease. Br HeartJ 1993;69:47-5 1.

4 Rashkind WJ, Cuaso CC. Transcatheter closure of apatent ductus arteriosus:successful use in a 3-5 kg infant.Pediatr Cardiol 1979;1:3-7.

5 Hellenbrand WE, Mullins CE. Catheter closure of con-genital cardiac defects. Cardiol Clin 1989;7:351-68.

6 Hourihan M, Perry SB, Mandell VS, Keane JF, Rome JJ,Bittl JA, Lock JE. Transcatheter umbrella closure ofvalvular and paravalvular leaks. JAm Coll Cardiol 1992;6:131-7.

480 on D

ecember 7, 2020 by guest. P

rotected by copyright.http://heart.bm

j.com/

Br H

eart J: first published as 10.1136/hrt.71.5.479 on 1 May 1994. D

ownloaded from