Percutaneous Closure of a Ruptured Sinus of Valsalva Aneurysm to Right Atrium Fistula
Presenter
Ivan Hanson, M.D., FSCAI, Beaumont Hospital - Royal Oak, Troy, MI
Nicholas P Kondoleon, MD, Beaumont Health, Troy, MI and Ivan Hanson, M.D., FSCAI, Beaumont Hospital - Royal Oak, Troy, MI
Title
Percutaneous Closure of Ruptured Sinus of Valsalva Aneurysm to Right Atrium Fistula
Introduction
Sinus of Valsalva aneurysm (SOVA) is rare, comprising 0.09% of the population. Rupture of SOVA can occur in 35% of patients and if left untreated has a median survival rate of two years. Over the past two decades, reports have emerged describing percutaneous closure strategies as an attractive alternative to mainstay surgical management for ruptured SOVA. In this case, a percutaneous strategy was used to close a SOVA to right atrium rupture in a non-operable patient presenting with cardiogenic shock.
Clinical Case
A 76-year-old man presented to the emergency department with chest pain radiating to the back. He had a pertinent history of a recently diagnosed, unruptured,
6.0cm SOVA with no follow up. The patient was classified as SCAI shock stage B, however, his condition deteriorated to SCAI shock stage D, manifesting as hypotension requiring norepinephrine, worsening mentation, and acute renal failure. CTA confirmed a 6.7cm aortic aneurysm with a thin dissection flap extending along the anterior and lateral root of the sinus of Valsalva and active extravasation of contrast into the right atrium. The aneurysmal neck diameter was 17mm. Subsequent TEE revealed a 6.5cm aortic root with a dissection flap into the wall of the right coronary cusp and rupture into the right atrium. Noted was nearly continuous, but predominantly diastolic flow, from the aorta into the right atrium with the defect on the atrial side measuring 0.7x0.6cm. Following discussion with cardiovascular surgery and the patient, the decision was made to pursue percutaneous closure of the defect. Femoral venous and arterial access was obtained. A multipurpose catheter was advanced into the aortic root and steered toward the fistula. A 0.035" J wire was used to cross the fistula and exchanged for a 0.035" Supercore wire positioned in the right atrium. Via the femoral venous sheath, a JR4 catheter was advanced into the right atrium and an Ensnare was advanced through the catheter to snare the Supercore wire. A 9F Torquevue sheath was advanced across the defect from the venous side and a 20 mm Amplatzer Septal Occluder was deployed uneventfully with mild residual shunting noted.
On Post-op day nine, a repeat TEE revealed a well seated occluder device with a mild to moderate sized peri-device leak. Labwork was revealing of a hemolytic anemia, for which pentoxifylline was started with stabilization of anemia. He was diuresed to a euvolemic state and discharged on post-op day 24. Two weeks following discharge the patient had improving anemia, stabilization of kidney function, resolution of dyspnea, and improvement in functional capabilities. Discussion
Percutaneous closure of ruptured SOVA with fistula into the right atrium is feasible, although there are no trans-catheter devices that are purpose-built for this type of defect. As such, incomplete closure may be the best possible outcome in non-operative patients, and may increase the likelihood of survival in the short term. In addition, pentoxifylline may be useful for device-related hemolysis associated with incomplete defect closure.