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Year : 2017  |  Volume : 1  |  Issue : 2  |  Page : 167-168

Multimodal imaging of dissecting sinus of valsalva aneurysms from right and left aortic sinuses and its management


1 Department of Paediatric Cardiology, Institute of Cardiovascular Diseases, Madras Medical Mission, Chennai, Tamil Nadu, India
2 Department of Cardiac Surgery, Institute of Cardiovascular Diseases, Madras Medical Mission, Chennai, Tamil Nadu, India

Date of Web Publication28-Aug-2017

Correspondence Address:
Kothandam Sivakumar
Department of Paediatric Cardiology, Institute of Cardiovascular Diseases, Madras Medical Mission, 4-A, Dr. J. Jayalalitha Nagar, Mogappair, Chennai - 600 037, Tamil Nadu
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jiae.jiae_37_17

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How to cite this article:
Sivakumar K, Doraiswamy V, Sheriff EA. Multimodal imaging of dissecting sinus of valsalva aneurysms from right and left aortic sinuses and its management. J Indian Acad Echocardiogr Cardiovasc Imaging 2017;1:167-8

How to cite this URL:
Sivakumar K, Doraiswamy V, Sheriff EA. Multimodal imaging of dissecting sinus of valsalva aneurysms from right and left aortic sinuses and its management. J Indian Acad Echocardiogr Cardiovasc Imaging [serial online] 2017 [cited 2020 Sep 29];1:167-8. Available from: http://www.jiaecho.org/text.asp?2017/1/2/167/213675



Ruptured sinus of valsalva aneurysms from the aortic root into cardiac chambers causes intracardiac shunts and detectable murmurs. When these aneurysms dissect into the left ventricular myocardium without rupturing, they alter the ventricular mechanics and electrical conduction and cause symptoms out of proportion to the clinical findings. This series of images shows such aneurysms from multiple sinuses of a symptomatic young adult male, who presented with retrosternal chest pains associated with effort dyspnea. Transesophageal echocardiogram and magnetic resonance imaging [[Figure 1]a,[Figure 1]b,[Figure 1]c,[Figure 1]d and [Video 1]a, [Video 1]b, [Video 1]c, [Video 1]d] showed large unruptured aneurysms from the right (A1) sinus burrowing into the interventricular septum and left (A2) sinuses burrowing into the lateral wall of the left ventricular outflow tract. There was no aortic regurgitation. After surgical pericardial patch closure of the aortic openings of the aneurysms, the distortion of the sinuses led to postoperative aortic regurgitation, which warranted aortic valve replacement with a mechanical prosthesis. On follow-up after 3 months, persistent flows were seen into an anterior aneurysm from the right aortic sinus through a residual restrictive patch leak [[Figure 2]a,[Figure 2]b,[Figure 2]c and [Video 2]a,[Video 2]b,[Video 2]c]. A posterior annular paravalvular regurgitation also additionally contributed to persistent dyspnea. Both the residual aneurysmal leak and paravalvular regurgitation were closed nonsurgically [[Figure 3]a,[Figure 3]b,[Figure 3]c,[Figure 3]d and [Video 3]a,[Video 3]b,[Video 3]c,[Video 3]d. Hemodynamic transseptal left ventricular pressure tracings showed elevated end diastolic pressures [Figure 4]a; pressure within the residual anterior aneurysm through the restrictive patch leak showed higher pressure within the aneurysmal sac than left ventricle indicating the reasons for the persistent dyspnea and altered ventricular mechanics caused by the intraseptal high-pressure aneurysm [Figure 4]b. On 2 years follow-up, after the catheter intervention, the patient has no symptoms, completely obliterated aneurysms, normal left ventricular, and prosthetic valve function.
Figure 1: Dissecting sinus of valsalva aneurysms from right and left aortic sinuses. Transesophageal echocardiogram in long axis with color flow mapping (a) and short axis view (b) showed two large dissecting sinus of valsalva aneurysms from aorta (Ao). Aneurysm from the anterior right aortic sinus (A1) burrowed into the interventricular septum between the left ventricle and right ventricle. The other aneurysm from the left sinus (A2) burrowed into the myocardium of the left ventricular outflow tract. On a cardiac magnetic resonance imaging in axial (c) and long axial (d) views, both the aneurysms measured more than 4 cm. LA - left atrium; RA - right atrium

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Figure 2: Postsurgical residual leak into the aneurysm and paravalvar regurgitation. Three months following surgical patch closure of the aortic entry to both aneurysms and replacement of aortic valve with a mechanical bileaflet prosthesis, transthoracic echocardiogram in parasternal long axis view (a) showed persistent diastolic flows from aorta (Ao) into the anterior dissecting aneurysm (A1). The valve-like mechanism caused by this leak led to high intracavitary pressures and progressive enlargement of this dissecting aneurysm. In addition, there was a posterior paravalvar regurgitation (arrow) measuring 6 mm × 4 mm seen on transesophageal X-plane imaging (b). Magnetic resonance imaging (c) clearly oriented the residual leak into the aneurysm anteriorly and a jet of the paravalvar regurgitation posteriorly (white arrow) in relation to the aortic prosthesis. LA - left atrium; LV - left ventricle; LVOT - left ventricular outflow tract; RA - right atrium; RVOT - right ventricular outflow tract; RV - right ventricle

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Figure 3: Transcutaneous closure of residual leak and paravalvar regurgitation. Aortic root angiogram in lateral view (a) showed the posterior paravalvar leak (solid arrow) and faint filling of the anterior sinus of valsalva aneurysm (A1). After a selective injection (b) into the aneurysmal cavity (A1), it was closed (3C) with a 10 mm Amplatzer vascular plug II (St. Jude Medical, Plymouth, MN, USA) through a 6 French Judkins right coronary guiding catheter. The posterior paravalvar leak was closed (d) with a 10 mm × 4 mm Amplatzer vascular plug III (solid white arrow). During the entire intervention, there was a continuous left ventricular pressure assessment through the transseptal sheath shown in dotted arrow. Ao - Ascending aorta; LV - left ventricle

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Figure 4: Hemodynamic pressure traces. Simultaneous left ventricular pressures after septal puncture and aortic root pressures (a) showed elevated end diastolic pressures. The systolic and diastolic pressures (b) in the anterior dissecting aneurysmal sac was higher than the left ventricle indicating a valve-like mechanism of the residual patch leak and explained the reason for its progressive enlargement. Ao and Ao Asc - Ascending aorta; LV - left ventricle; LV rudi - anterior sac

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  [Figure 1], [Figure 2], [Figure 3], [Figure 4]



 

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