228

Brief Communications

American

January 1992 Heart Journal

Kessler KM, Kieval J, Saksena S, Sanderson TL, Myerburg RL. Echographic features of oosterior left ventricular wall coli endocarditis. AM pseudoa&urysm due to Eschkrichia HEART J 1982;103:139-42. 4. Carlson EB, Wolfe WG, Kisslo J. Subvalvular left ventricle pseudoaneurysm after mitral valve replacement: two-dimensional echocardiographic findings. J Am Co11 Cardiol 1985;6: 1164-6. 5. Roelandt JRTC, Sutherland GR, Yoshida K, Hoshikawa J. Improved diagnosis and characterization of left ventricular pseudoaneurysm by Doppler flow imaging. J Am Co11 Cardiol 1988;12:807-11. 6. Roberts WC, Ianer JM, Virmani R. Left ventricular incision midway between the mitral anulus and the stumps of the papillary muscles during mitral valve excision with or without rupture or aneurysmal formation: analysis of 10 necropsy patients. AM HEART J 1982;104:1278-87. 3.

Role of transesophageal echocardiography in sinus of Valsalva aneurysm Patrice A. McKenney, and Susan E. Wiegers,

MD, Richard MD. Boston,

J. Shemin, Mass.

MD,

Sinus of Valsalva aneurysms are often complicated by rupture. Although the right atrium and ventricle are the most frequent sites, rupture can occur into the left ventricle, pulmonary artery, or pericardium.i Successful surgical management requires precise determination of the location and hemodynamic consequences of the lesion. We present a patient in whom transesophageal echocardiography was superior to transthoracic echocardiography in the assessment and management of a ruptured sinus of Valsalva aneurysm. s A Z&year-old woman was noted to have a heart murmur in 1983, thought to be a patent ductus arteriosus. She was asymptomatic and did not seek further medical care until November 1989, when she presented with increasing dyspnea on exertion and fatigue. A gated blood pool scan with flow study revealed a 3:l pulmonary-to-systemic flow ratio and an ejection fraction of 78%. In late December 1989, dental work was performed with prophylactic antibiotic administration before but not after the procedure. One month later the patient presented with fever, chills, and multiple blood cultures positive for Actinobacillus actinomycetemcomitans. The patient was treated for 4 weeks with intravenous antibiotics with resolution of fever; however, there was persistent dyspnea that manifested after she had climbed one flight of stairs. She was then referred From the Evans Memorial Department of Cardiothoracic and the Cardiology Section, Hospital. Reprint versity 4/4/33406

requests: Hospital,

Department of Clinical Research and the Surgery, Boston University Medical Center; Thorndike Memorial Laboratory of Boston City

Patrice A. McKenney, MD, Division of Cardiology, 88 E. Newton St., Boston, MA 02118.

Uni-

Fig. 1. Ruptured sinus of Valsalva aneurysm photographed underwater to show the classic “wind sock” appearance. The main orifice of the aneurysm measures 1 cm in diameter, with several smaller holes representing multiple sites of rupture. White arrow indicates the origin of the aneurysm in the noncoronary sinus of Valsalva. Black arrow indicates the site of rupture into the right atrium.

to this institution for further evaluation. The temperature was 98.6O F, the blood pressure was 120/30 mm Hg, and the heart rate was 80 beats/min. There was no jugular venous distension. The carotid pulses were bounding. The point of maximal impulse was in the fifth intercostal space, 1 cm lateral to the midclavicular line. A right ventricular lift was present. The first and second heart sounds were palpable. A grade 416 continuous murmur was heard over the entire precordium. Neither third nor fourth heart sounds were heard. The lungs were clear. There was no hepatomegaly, peripheral edema, or evidence of cutaneous emboli. The chest radiograph showed normal heart size and pulmonary markings. The electrocardiogram revealed normal sinus rhythm with evidence of left ventricular hypertrophy. Transthoracic echocardiography was notable for a dilated left ventricle with normal systolic function, and a fistula between the noncoronary sinus of Valsalva and the right atrium. Significant flow through the fistula occurred during both systole and diastole. Because of turbulent flow in that area, it was unclear whether aortic insufficiency was present. The patient was taken to the operative suite where intraoperative transesophageal echocardiography was performed. This study showed a ruptured noncoronary sinus of Valsalva aneurysm resulting in a fistula into the right atrium (Figs. 1 and 2). Clarification of the question of aortic insufficiency was required to assess the need for valve repair or replacement. In contrast to the transthoracic echocardiogram, the aortic valve was well visualized and

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2. Transesophageal echocardiogram in the standard four-chamber view with the black arrow showing the ruptured sinus of Valsalva aneurysm projecting into the right atrium (RA) as in Fig. 1. LA, Left atrium; LV, left ventricle; MV, mitral valve; RV, right ventricle; TV, tricuspid valve.

Fig.

appeared normal with no regurgitant flow into the left ventricle. The aneurysm was excised and repaired with a cryopreserved aortic homograft patch. One circular patch was sewn to the atria1 side of the fistula, and a second patch was sewn to the aortic side. After the patient was weaned from cardiopulmonary bypass, transesophageal echocardiography revealed significant left-to-right atria1 flow. The flow was suspected to be at the level of the foramen ovale, and did not originate at the site of the patch. Because of the new significant flow, cardiopulmonary bypass was reestablished and the atrium was explored with the aorta unclamped. A patent foramen ovale caused by stretching of the right atrium from the patch was found and was primarily repaired. No leaks were identified around the circumference of the atria1 patch. No abnormal flow was noted on subsequent transesophageal echocardiography. The initial postoperative course was unremarkable, but a new continuous murmur suddenly appeared on the seventh postoperative day. A transthoracic echocardiogram showed flow from the aorta into the right atrium at the site of the repair and aortic insufficiency, both of which were new and were confirmed on transesophageal echocardiography. The patient remained hemodynamically stable, but because of concern that the patch was deteriorating, the heart was reexplored. A leak was found due to a suture line dehiscence where the aortic homograft patch was sewn into the aortic wall 1 mm from the noncoronary leaflet. This was the site of the prior endocarditis and the aortic wall was quite friable in this area. In addition, two small tears of the noncoronary cusp of the aortic valve were also found and were repaired. No abnormal flow was present on postoperative transthoracic and transesophageal echocardiograms.

Brief Communications

229

The patient was discharged without further complications. The value of transesophageal echocardiography during cardiac valve surgery has increasingly been recognized.2 This case demonstrates that transesophageal echocardiography also allows the accurate localization and hemodyneeded for successful surgical repair of namic assessment a ruptured sinus of Valsalva aneurysm. Previous reports3-6 note that transthoracic echocardiography often visualizes the aneurysm, and the addition of color flow Doppler imaging allows localization of the rupture in many cases. In this case, transthoracic echocardiography correctly diagnosed the lesion, but transesophageal echocardiography was required to precisely evaluate the competency of the aortic valve preoperatively. The presence and severity of aortic insufficiency were key clinical issues in this patient, since we wished to avoid valve replacement in a young woman of childbearing age. In addition, transesophageal echocardiography was instrumental in localizing the development of a new left-to-right shunt after the repair to a patent foramen ovale. Postoperatively, it is important to monitor patients closely. In this patient, although the initial transesophageal echocardiogram revealed no abnormal flow at the site of the repair, 1 week later a leak developed at the site of the aortic homograft patch, along with aortic insufficiency. Where transthoracic echocardiography provides inadequate visualization of important structures, transesophageal echocardiography often provides additional useful information for postoperative monitoring and decision making. In summary, we report an unusual case of a ruptured sinus of Valsalva aneurysm in which transesophageal echocardiography was invaluable for successful surgical management. The information obtained by transesophageal echocardiography was instrumental both in formulating the surgical approach and in assessing the operative results. REFERENCES

1.

Sakakibara S, Konno S. Congenital aneurysm of the sinus of Valsalva: Anatomy and classification. AM HEART J 1962;

2.

Sheikh KH, DeBrujin NP, Rankin JS, Clements FM, Stanley T, Wolfe WG, Kisslo J. The utility of transesophageal echocardiography and Doppler color flow imaging in patients undergoing cardiac valve surgery. J Am Co11 Cardiol 1990,15:363-

63:405-24.

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Kiefaber RW, Tabakin BS, Coffin LH, Gibson TC. Unruptured sinus of Valsalva aneurysm with right ventricular outflow obstruction diagnosed by two-dimensional and Doppler echocardiography. J-Am Co11 Cardiol 1986;7:438-42. -4. Shaffer EM. Snider R. Beckman RH. Behrendt DM. Peschiera AW. Sinus of Valsalva aneurysm complicating bacterial endocarditis in an infant: diagnosis with two-dimensional and Doppler echocardiography. J Am Co11 Cardiol 1987;9:58891. 5. Chow LC, Dittrich HC, Dembitsky WP, Nicod PH. Accurate localization of ruptured sinus of Valsalva aneurysm by real time two-dimensional Doppler flow imaging. Chest 1988; 94:462-5. 6. Chiang CW, Lin FC, Fang BR, Kuo CT, Lee YS, Chang CH. Doppler and two-dimensional echocardiographic features of sinus of Valsalva aneurysm. AM HEART J 1988;5:1283-8. 3.

Role of transesophageal echocardiography in sinus of Valsalva aneurysm.

228 Brief Communications American January 1992 Heart Journal Kessler KM, Kieval J, Saksena S, Sanderson TL, Myerburg RL. Echographic features of o...
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