Percutaneous closure of ruptured sinus of Valsalva aneurysm: results from a multicentre experience

An observational study of symmetrical VSD occluder for transcatheter closure of ruptured sinus of Valsalva aneurysm

This study evaluated the immediate and 1-year postoperative outcomes of 14 patients with ruptured Valsalva aneurysmal sinus (RSVA) using symmetric ventricular septal defect (VSD) occluder for transcatheter closure (TCC). The sites of rupture were from the non-coronary sinus to the right atrium (RA) in 10 cases (71.4%), the right coronary sinus (RCS) to the RA in 3 cases (21.4%) and the RCS to the right ventricle in 1 case (7.2%). The defects (5-11 mm) were closed with a symmetrical VSD device. During the follow-up (12 months), the enlarged heart of the patients had significantly shrunk and the NYHA improved after closure. In 1 case, a moderate residual shunt was present and the patient suffered from hemolysis at 2 h after the operation, and 1 patient was transferred to surgery for aortic regurgitation 1 year after the initial treatment of RSVA. In conclusion, the TCC of RSVA with the China made symmetrical VSD occluder is safe and effective.

Transcatheter closure of a ruptured sinus of valsalva: a systematic review of the literature

Background

Ruptured sinus of Valsalva (RSOV) is a rare pathology, and current data regarding its symptoms, anatomy, associated pathologies, and appropriate therapeutic approaches are scarce. Transcatheter closure (TCC) has been performed in multiple cases; however, the information on its success rate and complications is limited.

Methods

Two independent reviewers performed an advanced search based on inclusion criteria on Scopus, PubMed, and Embase from January 1985 through July 2022. The main search terms were "Sinus of Valsalva", "Rupture/Aneurysm", and "Transcatheter/Catheter/Device".

Results

Totally, 1,017 relevant articles from the 3 databases were retrieved. After the final review and appraisal, 94 articles describing 407 patients who underwent the TCC of RSOV were included. Males comprised 65% of the studied patients, and the average age was 34.5 years. The total success rate of TCC was 95.6%. Forty-nine patients (12%) developed complications, the most significant of which were sustained residual shunts in 7 patients (1.7%), substantial new onset or progression of aortic insufficiency in 6 (1.5%), and RSOV recurrence in 6 (1.5%). Post-interventional mortality was reported in only 2 patients (0.5%).

Conclusions

The present study is the first systematic review of available data regarding the TCC of RSOV principally comprising case series and case reports. Although TCC seems a good option, precise patient selection is mandatory.

Percutaneous closure versus surgical repair for ruptured sinus of valsalva aneurysm: A systematic review and meta-analysis

Objectives

Ruptured sinus of Valsalva aneurysm (RSVA) often has an abrupt onset, and can chest pain, acute heart failure, and even sudden death. The effectiveness of different treatment modalities remains controversial. Thus, we completed a meta-analysis to evaluate the efficiency and safety of traditional surgery vs. percutaneous closure (PC) for RSVA.

Methods

We carried out a meta-analysis using PubMed, Embase, Web of Science, Cochrane Library, China National Knowledge Infrastructure (CNKI), WanFang Data, and the China Science and Technology Journal Database. The primary outcome was comparing in-hospital mortality between the two procedures, and the secondary outcome was documenting postoperative residual shunts, postoperative aortic regurgitation, and length of hospital stay in the two groups. Differences were expressed as odds ratios (ORs) with 95% confidence intervals (CIs) to assess the relationships between predefined surgical variables and clinical outcomes. This meta-analysis was conducted using Review Manager software (version 5.3).

Results

The final qualifying studies included 330 patients from 10 trials (123 in the percutaneous closure group, and 207 in the surgical repair group). When PC was compared to surgical repair, there were no statistically significant differences in in-hospital mortality (overall OR: 0.47, 95%CI 0.05-4.31, P = 0.50). However, percutaneous closure did significantly decrease the average length of hospital stay (OR: -2.13, 95% CI -3.05 to -1.20, P < 0.00001) when compared to surgical repair, but there were no significant between-group differences in the rates of postoperative residual shunts (overall OR: 1.54, 95%CI 0.55-4.34, P = 0.41) or postoperative aortic regurgitation (overall OR: 1.54, 95%CI 0.51-4.68, P = 0.45).

Conclusion

PC may become a valuable alternative to surgical repair for RSVA.

Case report: Unruptured sinus of Valsalva aneurysms causing postural angina pectoris and false "pulmonary hypertension"

A 37-year-old woman presented with worsening intermittent chest pain and dyspnea in the previous year. Although the dyspnea was exertion-dependent, her chest pain was heavily dependent on her postural position, worsening in the supine position but alleviated by lying prone or by sitting up and leaning forward. She was cyanotic, and a diastolic murmur in the left third intercostal space was auscultated. An electrocardiogram recorded when she laid flat and had angina pectoris attacks showed ST-segment elevation in the aVR and depression in the II, III, aVF, and V3-V6 leads. However, when she sat up for a few minutes, her symptoms and ST-segment abnormalities disappeared. Echocardiography and cardiac computed tomography angiography revealed large unruptured aneurysms of the left and non-coronary sinuses, along with a dilated aortic root, severe aortic regurgitation, and right ventricular high pressure. Coronary angiography showed ∼90% pulsating stenosis of the left main coronary artery and ∼80% pulsating stenosis of the proximal left circumflex artery, presumably caused by pulsation of the dilated sinus of Valsalva aneurysm under blood pressure. Genetic testing revealed c.1781 C > G nonsense mutations in the FLNA gene. The patient underwent surgery, which confirmed dual unruptured left/non-coronary sinus of Valsalva aneurysms. Our case illustrates an unusual postural form of angina pectoris and false "pulmonary hypertension" caused by large dual unruptured left/non-coronary sinus of Valsalva aneurysms.

Association of ruptured sinus of Valsalva aneurysm and congenital ventricular septal defect: a case series

Background

Ruptured sinus of Valsalva aneurysm (RSOVA) is rare, and it is more common in Asians. Typically, the patient presents with acute/subacute shortness of breath (SOB) and chest pain. Echocardiography is the gold standard for diagnosis in most of these cases. Surgery has remained the first line of management.

Case summary

We present two cases of RSOVA in which the patients presented to the emergency department with SOB. Their preoperative echocardiography results showed RSOVA into the right ventricle. During surgical repair, ventricular septal defect (VSD) was also found.

Discussion

RSOVA is frequently associated with other congenital anomalies, and most often with VSD. In our cases, we believe that VSDs were missed preoperatively because either the large aneurysmal sacs covered the VSD or there was overlap between the two shunts. Additionally, in the first case, right ventricular pressure was high approaching systemic pressure, which probably reduced the shunt across the VSD. Early intervention is recommended to prevent endocarditis or enlargement of the ruptured aneurysm; long-term results were excellent after surgical repair. Most patients undergo surgery between 20 and 40 years of age, and the reported survival rate is 95% at 20 years. If left untreated, patients typically die of heart failure or endocarditis within 1 year after onset of symptoms.

Case Report: Transcatheter Closure of Ruptured Sinus of Valsalva With Ventricular Septal Defect Occluder in a 3-Year-Old Child After Repair of Ventricular Septal Defect

Sinus of Valsalva aneurysm (SVA) is a rare cardiac anomaly that can undergo spontaneous rupture into other cardiac chambers or the pericardial space. A ruptured SVA has a very poor prognosis with high morbidity and mortality. These aneurysms often present as a rupture from the right coronary sinus into the right ventricle. Transcatheter closure has become an effective alternative to surgical treatment. However, it has been rarely reported in patients after ventricular defect repair in the past. We here describe a 3-year-and-3-month-old boy who was found to have a ruptured sinus of Valsalva. He underwent surgical closure of a ventricular septal defect at the age of 2 months, which occurred in the non-coronary sinus (NCS) and ruptured into the right atrium. We successfully occluded the ruptured sinus of Valsalva with a ventricular septal occluder.

Comparison of clinical results between percutaneous closure and surgical repair of ruptured sinus of Valsalva aneurysm

OBJECTIVES

This study was conducted to investigate whether percutaneous closure of ruptured sinus of Valsalva aneurysm (SVA) is as safe and effective as surgery repair.

BACKGROUND

Percutaneous closure of ruptured SVA has been becoming an alternative to the traditional surgical repair recently. The reports regarding direct comparison of these two treatment options are scarce.

METHODS

The medical records from the institutional database were retrospectively analyzed. A total of 134 patients were reviewed, including 26 patients undergoing percutaneous closure and 108 patients being treated surgically. To reduce the potential bias, 32 patients from Surgical Repair group were selected by propensity score matching.

RESULTS

All the ruptured SVAs were successfully closed in each group. No severe procedure-related complications were found in the perioperative period. After matching, there were no significant differences in the baseline clinical characteristics. The median postoperative hospital stays of Matched group were significantly longer than that of Percutaneous Closure group (7 days vs. 1 day, p < .001). Aortic regurgitation, residual shunt and recurrence of SVAs were common complications in both Percutaneous Closure group and Surgical Repair group.

CONCLUSIONS

The appropriately selected patients with ruptured SVA could be treated by percutaneous closure with an acceptable risk of short-term complications. Though surgical repair remains the main treatment option for ruptured SVAs, percutaneous closure could be considered in patients with a small-size rupture and no associated cardiac abnormalities.

Transcatheter Closure of Ruptured Sinus of Valsalva Aneurysm with Double-Disc Perimembranous VSD Occluder in Man with Mechanical Aortic Valve

Sinus of Valsalva aneurysm, a rare cardiac anomaly, can be life-threatening if it ruptures. Transcatheter closure has emerged as an effective alternative to surgical management; however, it has rarely been reported in patients with previous mechanical aortic valve replacements. We describe the case of a 45-year-old man who presented with a ruptured aneurysm of the noncoronary sinus of Valsalva 14 years after the implantation of a mechanical aortic valve. The ruptured aneurysm was closed by transcatheter means with use of a double-disc perimembranous ventricular septal defect occluder. The patient remained asymptomatic one year after the procedure. Our case suggests that transcatheter closure with use of this type of occluder is a viable method for successfully repairing ruptured sinus of Valsalva aneurysms in patients who have mechanical aortic valves.

Medium- and long-term follow-up of transcatheter closure of ruptured sinus of Valsalva aneurysm in Central Europe population

BACKGROUND

We aimed to evaluate medium- and long-term outcomes of transcatheter closure (TC) of ruptured sinus of Valsalva aneurysm (RSVA), which is a rare and mostly congenital heart disease.

METHODS

Retrospective analysis included 23 patients (14 males) aged 15-79 years (y; 39.9±18.5) selected for TC of RSVA between 2007 and 2017 in two tertiary centers in Poland and Ukraine. Fifteen patients were in New York Heart Association (NYHA) class III or IV before TC; 5 patients had acquired RSVA after previous cardiac surgery. We applied 22 duct, 3 muscular, and 1 atrial septal Amplatzer or Amplatzer-like occluders by the anterograde venous approach after arterio-venous loop creation in all but 1 patient. Mean follow-up conducted in outpatient clinic was 5.5±3.5 (1-11)y.

RESULTS

The procedure was successful in 19/23 patients (82.6%). Four procedures were abandoned and the device percutaneously retrieved due to coronary artery compression (1 patient), transient increase of aortic regurgitation (AR; 1 patients) or embolization (2 patients). New onset of significant AR was noted in one of the latter patients after device removal. NYHA class improved in all treated patients but 2, in whom it remained stable (p<0.05), with 10 patients in class I. Three patients needed percutaneous re-intervention during follow-up because of significant residual shunt in 1 and late recurrent RSVA in 2 patients. The follow-up of the remaining patients was uneventful. Neither erosion, embolization, new AR, nor death were observed.

CONCLUSIONS

The percutaneous closure of RSVA is a safe and effective method of treatment with good clinical outcome. However, although not described previously, recurrent shunts after TC of RSVA are possible and can be treated successfully with another transcatheter intervention.

Safety and efficacy of percutaneous closure of ruptured sinus of Valsalva aneurysm

AIMS

The aim of this study was to evaluate the safety and efficacy of percutaneous closure in patients with a ruptured sinus of Valsalva aneurysm (RSVA).

METHODS AND RESULTS

A total of 29 patients with RSVA were retrospectively enrolled in our study. All patients were successfully treated by percutaneous closure and had a complete closure at discharge; however, two patients had a trivial procedure-related aortic regurgitation (AR) after the procedure. On a mean follow-up of 29.7±23.8 months (range 1-83 months), the two procedure-related AR disappeared three months and two years after the procedure, respectively. Trivial residual shunt was found in one patient, sinus of Valsalva aneurysm ruptured again in one patient and trivial to moderate AR was found in two patients during the follow-up.

CONCLUSIONS

In appropriately selected patients with RSVA, percutaneous closure is an attractive alternative to surgery with high technical success and good short-term and midterm outcomes; however, long-term follow-up is mandatory.

Transcatheter closure of postsurgical ruptured sinus of Valsalva with Amplatzer Duct Occluder II AS™ device

Sinus of Valsalva (SV) rupture is a rare, cardiac complication after surgical repair of complex congenital heart disease. This paper reports a 4-year-old male child with double outlet right ventricle (RV) and pulmonary stenosis with superior-inferior arrangement of the ventricles, who was submitted to surgical repair using the “reparation a l’etage ventriculaire” procedure. A few months after an uneventful surgical repair, his clinical condition abruptly worsened because of the rupture of the right SV into the RV outflow tract resulting in large left-to-right shunt and RV functional impairment. To avoid surgical re-do, this late-onset complication was successfully treated by transcatheter implantation of an Amplatzer Duct Occluder Type II Additional Size™ (ADO-IIAS, St. Jude Medical Inc., St. Paul, Minnesota, USA) device.

Angina pectoris and sinus of Valsalva aneurysm: a rare manifestation of an uncommon disease

Sinus of Valsalva aneurysm is an uncommon finding. The present paper describes a case report of a 57-year-old female patient who developed angina pectoris due to the left sinus of Valsalva aneurysm. Clinical presentation, localization, unruptured status and concomitant coarctation of the aorta make the case presented in this document extremely rare and interesting. Current knowledge about the disease is briefly discussed.