Catheterization and Cardiovascular Interventions 84:1184–1189 (2014)

VALVULAR AND STRUCTURAL HEART DISEASES Original Studies Clinical Efficacy and Safety of Transcatheter Closure of Ruptured Sinus of Valsalva Aneurysm Li Zhong,1 MD, PhD, Shi-Fei Tong,1 MD, PhD, Qian Zhang,1 MD, PhD, Zhi-Hui Zhang,1 MD, PhD, Qing Yao,1 MD, PhD, Yong-Hua Li,1 MD, PhD, Wei-Hua Zhang,2 MD, and Zhi-Yuan Song,1* MD Objectives: To evaluate the clinical efficacy and safety of transcatheter closure (TCC) in patients with ruptured sinus of Valsalva aneurysm (RSVA). Background: RSVA is a rare cardiovascular disease with a varied clinical presentation. The clinical efficacy and safety of TCC for RSVA still remain an ongoing concern. Methods: From January 2009 to March 2013, 22 patients with RSVA were selected for TCC. Intracardiac pressure and size of cardiac chamber were measured before and post TCC. All patients were followed up by transthoracic echocardiography at 1, 3, 6, 12 months after procedure. Results: RSVA was successfully occluded in 20 patients (19 cases with Amplatzer duct occluder and one with muscular ventricular septal defect occluder). Aortic root angiography showed no shunt in 18 cases and a small residual shunt in two cases. The pressures in the right atrium, right ventricle, and pulmonary artery were significantly decreased after the procedure (P < 0.01), and the aortic pressure was elevated (P < 0.001). The internal diameters of the right atrium, left atrium, and left ventricle were also significantly declined after the procedure (P < 0.05). No complications were found after 18.5 6 6.5 (range 3–35) months follow-up. Two patients underwent acute surgical aortic valve replacement because of procedure-related aortic valve regurgitation. Conclusions: Our results indicate that TCC is a promising alternative therapy to surgery in appropriate patients with RSVA. However, rare but severe procedure-related complications should be considered in the risk assessment. VC 2013 Wiley Periodicals, Inc. Key words: sinus of Valsalva aneurysm; Amplatzer duct occluder; transcatheter closure; aortic valve regurgitation

INTRODUCTION

Sinus of Valsalva aneurysm (SVA) is relatively common in Asian [1]. The weakness at junction of the aortic media and the annulus fibrosis leads to the formation of aneurysm. Patients are usually asymptomatic before rupture of SVA (RSVA). However, RSVA into one of cardiac chamber will cause profound hemodynamic change and worsening of symptoms [2]. Surgical repair has been the traditional treatment for RSVA. Successful transcatheter closure (TCC) for RSVA is being increasingly reported since 1994 [3]. However, most of previous reports were single case reports or small series without information of left ventricular (LV) function and echocardiography parameters after procedure [4–13]. In the present report, we C 2013 Wiley Periodicals, Inc. V

described the safety and efficacy of TCC on 22 RSVA cases with special focus on hemodynamic change, indication, and severe procedure-related complications. 1

Department of Cardiology, Southwest Hospital, Third Military Medical University, Chongqing, 400038, China 2 Department of Cardiology, Yan’an Hospital, Kunming Medical University, Yunnan, 650051, China Conflict of interest: Nothing to report. *Corresponding to: Zhi-Yuan Song; Department of Cardiology, Southwest Hospital, Third Military Medical University, Chongqing 400038, China. E-mail: [email protected] Received 14 August 2013; Revision accepted 28 November 2013 DOI: 10.1002/ccd.25323 Published online 18 December 2013 in Wiley Online Library (wileyonlinelibrary.com)

Ruptured Sinus of Valsalva Aneurysm

1185

Fig. 1. The aneurysm of right coronary sinus ruptured into right ventricular outflow tract, which was shown by aortagram in the right anterior oblique view (A). Repeated aortagram showed complete occlusion of RSVA with ADO (B).

MATERIAL AND METHODS Patient Characteristics

From January 2009 to March 2013, 23 patients with RSVA were chosen for TCC. One case was excluded for suspicious infective endocarditis before procedure. Twenty-two patients (15 males and seven females) were 18–47-years old (mean age, 30.3 6 8.2 years). All of the patients were admitted for sudden onset of palpitation, chest distress, and shortness of breath in our hospital, and 16 (72.7%) of out of 22 patients coexisted with mild or moderate edema in lower extremities. Four patients were in NYHA class III, 10 in class II, and eight in class I. Auscultation revealed continuous grade III–VI murmur over the third and fourth left parasternal area in all patients. One case had bicuspid aortic valve with mild aortic valve regurgitation (AR). One case underwent surgical aortic valve replacement (AVR) because of aortic valve disease before 3 years. All patients underwent attempted TCC of RSVA after obtaining informed consent. Devices Amplatzer duct occluder (ADO; AGA Medical Corporation, MN) was used for 19 cases; one case with acquired RSVA was occluded by muscular ventricular septal defect (VSD) occluder (MVSDO; AGA Medical Corporation, MN). We selected the size of occluder with 2–5mm larger than the diameter of aortic opening of RSVA which was measured by aortic root angiography or echocardiogram.

Procedure The procedure was carried out under local anesthesia and monitored using both fluoroscopy and transthoracic echocardiography (TTE). After right femoral arterial and venous were accessed, intravenous heparin (80 U/ kg) was given. Right atrium systolic pressure (RASP), right ventricle systolic pressure (RVSP), pulmonary arterial systolic pressure (PASP), and aorta systolic pressure (AoSP) were measured. Pulmonary to systemic flow ratio (Qp/Qs) was calculated. A 6F pigtail catheter was introduced and aortic root angiography was carried out to measure the aortic opening of the RSVA (Figs. 1A and 2A). Next, a 5F Judkins right coronary catheter and a hydrophilic wire were crossed the opening from aorta side. A 260 cm exchanged wire was grasped by an Amplizar gooseneck snare (Microvena, White Bear Lake, MN) and pulled out of the femoral vein. The stable arteriovenous wire loop was thus established. Over the wire, an Amplizar delivery sheath was introduced from femoral vein through the ruptured sinus to the ascending aorta. Under the guidance of fluoroscopy and echocardiogram, an appropriately sized ADO with delivery cable was inserted through the delivery sheath from the venous route, and was deployed in the opening of RSVA (Figs. 1B and 2B). Aortogram was repeated to confirm the occlusion of the RSVA and no significant aortic valve regurgitation resulting from the occluders. For patients with SVA originated from the right coronary sinus (RCS) or noncoronary sinus (NCS), selective coronary angiography was performed to make sure the ostium of RCS or

Catheterization and Cardiovascular Interventions DOI 10.1002/ccd. Published on behalf of The Society for Cardiovascular Angiography and Interventions (SCAI).

1186

Zhong et al.

Fig. 2. A 47-year-old man with the surgical aortic valve replaced for 3 years, aortagram in the left anterior oblique showed aneurysm of non coronary sinus rupturing into right ventricle. The opening of aortic opening was about 4 mm (A). Repeated aortagram showed complete occlusion of rupture after the deployment of 8-mm MVSDO (B).

LCS was not affected. Once the position was confirmed acceptable, the ADO was finally released from the delivery cable. The pressures of right atrium, right ventricle, and pulmonary artery were measured again. Prophylactic antibiotics were routinely administrated after procedure for 3 days; subcutaneous injection of low-molecular heparin (1 mg/kg, bid) was given for 2 days, followed by 6 months of oral administration of aspirin (3–5 mg/kg). Echocardiography All patients were followed up by TTE at 1, 3, 6, 12 months after procedure. TTE were performed at the Southwest Hospital Echocardiography Laboratory, Chongqing, China. LV ejection fraction (LVEF) derived from two-dimensional measurement or M-mode; LV end-diastolic dimension (LVEDD) and LV end-systolic dimension in sinus rhythm were also measured. Statistical Analysis The continuous data were presented as mean 6 standard deviation. A paired t test was used to compare RASP, RVSP, PASP, and AoSP before and after procedure to detect the change of the internal diameter of heart chambers. A P-value of less than 0.05 was considered to be significant. RESULTS

The detailed clinical characteristics of patients were showed in Table I. TEE and aortagraphy showed RSVA

from RCS to RA in two patients and right ventricular outflow tract in eight patients. SVA from NCS ruptured to RA was found in 11 patients and RV inflow in one. The mean diameters of the SVA and aortic opening were 16.2 6 1.8 mm and 6.7 6 1.6 mm, respectively. The distance between the opening of the SVA and the aortic valve ring was 12–20 mm (Table I). The occluder was successfully deployed in 20 out of 22 patients (success rate, 91%). Of these 20 patients, 18 had completely closure and two had a trace residual shunt. Two patients (case 9 and case 16) underwent emergent surgical AVR because of procedure-related severe AR and acute left heart failure. RASP, RVSP, PASP, and AoSP of the successful 20 patients were measured before and after procedure. RASP, RVSP, and PASP were significantly decreased after successful TCC (all P < 0.01), but the AoSP was elevated remarkably (P < 0.001; Table II). The internal diameters of the right atrium, left atrium, and right ventricular and LVEDD were significantly decreased and LVEF significantly increased after 3 months follow-up (all P < 0.05; Table III). All patients underwent successful TCC were followed up 18.5 6 6.5 (range 3–35) months. The symptoms of palpitation, chest distress, and shortness of breath disappeared in 3 days after procedure. The edema of lower extremity in 16 patients disappeared within 1 week after procedure. Seventeen patients had NYHA class I and two in class II. Two patients had small residual shunt after procedure. Of successful TCC patients, nonprocedure-related aortic regurgitation was detected. Two patients underwent emergent

Catheterization and Cardiovascular Interventions DOI 10.1002/ccd. Published on behalf of The Society for Cardiovascular Angiography and Interventions (SCAI).

Ruptured Sinus of Valsalva Aneurysm

1187

TABLE I. Clinical Data and Transcatheter Therapy Results (n 5 22) Diameter of SVA (mm)

Diameter of aortic opening (mm)

Qp/Qs

ADO size (mm)

Sex

Age (years)

RSVA (Connection)

1 2 3 4 5 6 7 8 9

F M M F M M M M M

19 18 18 38 34 28 35 25 32

NCS-RA RCS-RVOT RCS-RVOT RCS-RVOT NCS-RA NCS-RA RCS-RVOT NCS-RA RCS-RA

None None None None Mild AR None None None Bicuspid aortic valve

16 16 15 16 19 16 17 18 21

5 6 5 7 9 7 6 8 10

1.3 1.7 1.4 1.9 2.0 1.5 1.6 2.1 2.5

12/10 14/12 12/10 14/12 16/14 14/12 14/12 16/14

10 11 12 13 14 15 16

F F M M M M M

28 42 47 32 33 28 21

NCS-RA RCS-RVOT RCS-RVOT NCS-RA NCS-RA NCS-RA RCS-RA

None None None None Mild AR None None

14 16 14 15 15 17 18

6 6 4 6 8 7 9

1.5 1.6 1.4 1.6 1.8 1.6 2.2

12/10 14/12 MVSDO/8 12/10 /12/10 14/12

17 F 18 M 19 F 20 M 21 M 22 M Mean 6 SD

40 29 26 34 40 20

NCS-RA RCS-RVOT NCS-RA NCS-RA NCS-RV inflow RCS-RVOT 30.3 6 8.2

None None None None Mild AR Mild AR

16 14 17 16 14 15 16.1 6 1.8

8 6 8 5 4 7 6.7 6 1.6

1.4 1.3 1.7 1.3 1.3 1.9 1.6 6 0.3

12/10 12/10 14/12 12/10 8/6 12/10 12.9 6 1.8/ 10.9 6 1.8

Patient

Association

Residual shunt No No No No No Small No Small Failed, emergency surgical aortic valve replacement No No No No No No Failed, emergency surgical aortic valve replacement No No No No No No

RSVA, ruptured sinus of valsalva aneurysm; SVA, sinus of Valsalva aneurysm; RCS, right coronary sinus; NCS, noncoronary sinus; RA, right atrium; RV, right ventricle; RVOT, right ventricle outflow tract; QP/QS, pulmonary to systemic flow ratio; ADO, Amplatzer duct occluder; MVSDO, Amplatzer muscular VSD occluder. TABLE II. Pressure Changes after Transcatheter Closure of RSVA (mean 6 SD, n 5 20)

RASP (mm Hg) RVSP (mm Hg) PASP (mm Hg) AoSP (mm Hg)

Before

After

P valuea

14.43 6 4.52 38.12 6 8.08 37.89 6 8.70 103.28 6 5.35

8.23 6 2.40 29.56 6 4.39 28.53 6 5.01 112.34 6 6.01

0.002

Clinical efficacy and safety of transcatheter closure of ruptured sinus of valsalva aneurysm.

To evaluate the clinical efficacy and safety of transcatheter closure (TCC) in patients with ruptured sinus of Valsalva aneurysm (RSVA)...
155KB Sizes 0 Downloads 0 Views