LETTERS TO THE EDITOR
REFERENCES 1. Sfeir PM, Abchee AB, Ghazzal Z, et al: Endovascular transcatheter aortic valve implantation: An envolving standard. J Cardiothorac Vasc Anesth 27:765-778, 2013 2. Ionescu AA, Newman GR, Butchart EG, et al: Morphologic analysis of a strand recovered from a prosthetic mitral valve: No evidence of ﬁbrin. J Am Soc Echocardiogr 12:766-768, 1999 3. Nighoghossian N, Derex L, Perinetti M, et al: Course of valvular strands in patients with stroke: Cooperative study with transesophageal echocardiography. Am Heart J 136:1065-1069, 1998 4. Dangas G, Dailey-Sterling FG, Sharma SK, et al: NonQ-wave infarction and ostial left coronary obstruction due to giant Lambl’s excrescences of the aortic valve. Circulation 99:1919-1921, 1999 5. Aziz F, Baciewicz FA Jr: Lambl’s excrescences: Review and recommendations. Tex Heart Inst J. 34:366-368, 2007
The Use of Real-Time Three-Dimensional Transesophageal Echocardiography for Percutaneous Closure of a Ruptured Sinus of Valsalva Aneurysm To the Editor: We read with great interest the article by Mukherjee et al entitled “Is real time 3D transesophageal echocardiography a feasible approach to detect coronary ostium during transapical aortic valve implantation?”1 As argued, real-time, 3D echocardiography can provide both diagnostic and procedural advantages in interventional cases taking place in the cardiac catheterization laboratory, and we therefore report a case in which real-time 3D transesophageal echocardiography (3D TEE) helped guide the percutaneous closure of a ruptured sinus of Valsalva aneurysm. Sinus of Valsalva aneurysms are rare cardiac disorders that can lead to signiﬁcant morbidity if ruptured. Although deﬁnitive treatment traditionally has mandated operative repair, percutaneous interventions are being explored as a viable alternative.2,3 Twodimensional TEE (2D TEE) has been used as a primary diagnostic modality for these lesions, but has limitations for use in guidance of interventional procedures. We therefore present a patient in whom real-time 3D TEE helped guide the percutaneous closure of a sinus of Valsalva aneurysm. A 44-year-old Asian man presented to an outside hospital with new onset of dyspnea on exertion and fatigue. A diagnostic electrocardiogram revealed atrial ﬂutter, and transthoracic echocardiography (TTE) demonstrated a sinus of Valsalva aneurysm that had ruptured from the aorta into the right atrium, leading to right atrial enlargement. Surgical intervention was offered at that time, which the patient refused, seeking a second opinion at our institution. A preoperative 2D TEE performed by a cardiologist in the echocardiography
laboratory localized the rupture to the right coronary sinus of Valsalva, adjacent to the septal attachment of the tricuspid valve. Given the patient’s reluctance to undergo surgical repair, he was offered the option of percutaneous closure of the defect with the understanding that surgical repair would be indicated should the percutaneous intervention fail. In the cardiac catheterization laboratory, general anesthesia was induced via intravenous administration of lidocaine, fentanyl, propofol, and rocuronium and maintained with inhaled sevoﬂurane (1.7-2.3% end-tidal concentration). General anesthesia was chosen for this procedure given the need for TEE for procedural guidance and for the potential for hemodynamic instability during the intervention. 3D TEE (Philips iE33 machine in live 3D mode, Philips Healthcare, Andover, MA) performed by the cardiac anesthesiologist localized the rupture to the non-coronary sinus of Valsalva with communication into the right atrium and an oriﬁce diameter of 8 millimeters in contrast to the preoperative TTE ﬁndings (Fig 1A). Cardiac catheterization- and angiography-based diagnoses were consistent with the 3D TEE ﬁndings in terms of location and size; 3D TEE, therefore, allowed precise delineation of the size and shape of the defect. The cardiologist opted for a 10-mm VSD Amplatzer device (AGA Medical, Plymouth, Minnesota) based on these ﬁndings. Under ﬂuoroscopic, 2D, and 3D TEE guidance, the Amplatzer device was deployed against the sinus of Valsalva aneurysm (Fig 1B-1D) (Video 1). TEE examination immediately following device occlusion ruled out residual shunting around the device, thus conﬁrming effective closure (Figs 2 and 3A) (Video 2). TEE also ruled out new aortic or tricuspid valve dysfunction, which are theoretical complications of device placement in the aortic root and right atrium (Fig 3B) (Video 3). Postoperative TTE on day 1 conﬁrmed no residual shunting around the device. The patient has been followed regularly in the cardiology clinic; on his most recent visit one year after the procedure he denied any further episodes of arrhythmia or dyspnea on exertion. Follow-up echocardiography at 1 year revealed no residual shunt between the aortic root and right atrium with intact valvular, systolic, and diastolic function. Sinus of Valsalva aneurysms are rare congenital defects due to weakness of the aortic wall at the junction of the aortic media and annulus ﬁbrosa. Aneurysms most commonly occur in the right coronary sinus (65-85%) or noncoronary sinus (10-30%); aneurysms of the left coronary sinus are rare (o5%)4,5 Total incidence ranges from 0.1 to 3.5%, although the exact prevalence is unknown as most are diagnosed only after rupture.5 These aneurysms occur more commonly in men, as well as in Asian populations.6 Consequences of rupture may be severe, including arrhythmias, conduction disturbances, myocardial ischemia, tamponade, and even sudden death.7 Although deﬁnitive treatment traditionally has mandated operative repair, percutaneous interventions are being explored as a viable alternative.8,9 Further lending credence to exploring alternative treatment methods is the fact that surgical mortality may be high; a series of 129 patients was found to have a perioperative mortality of 3.9%.10 Cullen et al described the ﬁrst percutaneous closure of a sinus of Valsalva aneurysm in 1994, and since then, percutaneous intracardiac defect repairs steadily have been gaining favor.11 Recent advances in 3D TEE technology allow real-time imaging at high temporal and spatial resolution required for
LETTERS TO THE EDITOR
Fig 1. A. Three-dimensional image of ruptured noncoronary sinus of Valsalva aneurysm (arrow indicates rupture). B. Fluoroscopic image of catheter with Amplatzer device directed toward the sinus of Valsalva aneurysm (arrow indicates device predeployment). C. 2D TEE image with arrow indicating guidewire traversing ruptured sinus. D. 3D TEE image with arrow indicating guidewire traversing ruptured sinus. Abbreviations: Ao, aorta; IVC, inferior vena cava; LA, left atrium; RA, right atrium.
accurate tracking of catheters and devices as well as delineating precise cardiac anatomy during interventional procedures. Indeed, several previous cases have described the utility of real-time 3D TEE in percutaneous closure of the sinus of Valsalva aneurysms.12-14 Older 3D echocardiography techniques, while helpful in identifying the 3D anatomy, were limited
in serving as real-time monitors and diagnostic tools during interventional procedures.15 In our case, TEE in “live 3D mode” was instrumental in conﬁrming the precise location, shape and size of the defect, helping to determine the size of the device required, and ensuring efﬁcacy of the closure. 3D TEE imaging provided intricate details of the aneurysm in
LA Ao Ao RA RA IVC
Fig 2. A. Fluoroscopic image, B. 2D TEE image, and C. 3D TEE image revealing successful closure of ruptured noncoronary sinus of Valsalva aneurysm. Abbreviations: Ao, aorta; IVC, inferior vena cava; LA, left atrium; RA, right atrium. Arrows indicate device.
LETTERS TO THE EDITOR
Fig 3. Successful closure of ruptured noncoronary sinus of Valsalva aneurysm. 2D imaging reveals A. lack of residual shunt, and B. no new aortic valve dysfunction. Abbreviations: Ao, aorta; LA, left atrium; LV, left ventricle; RA, right atrium. Arrow indicates device.
multiple planes, allowing for more accurate anatomic detail and revealing that the aneurysm was in the non-coronary sinus, not the right coronary sinus as the preoperative 2D TTE erroneously had diagnosed. While improvement in outcomes with 3D TEE over 2D TEE will be difﬁcult to prove, live 3D TEE imaging does indeed allow for precise visualization of complex spatial relationships between critical anatomic structures, which may be out-of-plane when using 2D imaging modalities. Indeed, while passing the guidewire across the ruptured sinus of Valsalva, the only imaging modality that deﬁnitively showed the wire in both the aorta and the right atrium was 3D TEE (Fig 1, BCD). 3D TEE thus allowed safe, effective, and efﬁcient navigation of the device to the site of the defect while reducing use of ﬂuoroscopy and exposure to ionizing radiation. As percutaneous techniques in the cardiac catheterization laboratory become more common, there likely will be an increasing role for 3D TEE in both diagnosis and operative management of these lesions.
Jason H. Chua, MD Emily Methangkool, MD Catherine M. Cha, MD Aman Mahajan, MD, PhD Department of Anesthesiology, David Geffen School of Medicine at UCLA, University of California Los Angeles (UCLA), Los Angeles, CA
REFERENCES 1. Mukherjee C, Hein F, Holzhey D, et al: Is real time 3D transesophageal echocardiography a feasible approach to detect coronary ostium during transapical aortic valve implantation. J Cardiothorac Vasc Anesth 27:654-659, 2013 2. Arora R, Trehan V, Rangasetty UM, et al: Transcatheter closure of ruptured sinus of Valsalva aneurysm. J Interven Cardiol 17:53-58, 2004 3. Zhao SH, Yan CW, Zhu XY, et al: Transcatheter occlusion of the ruptured sinus of Valsalva aneurysm with an Amplatzer duct occluder. Int J Cardiol 129:81-85, 2008 4. Fishbein MC, Obma R, Roberts WC: Unruptured sinus of Valsalva aneurysm. Am J Cardiol 35:918-922, 1975 5. Feldman DN, Roman MJ: Aneurysms of the sinuses of Valsalva. Cardiology 106:73-81, 2006 6. Chu SH, Hung CR, How SS, et al: Ruptured aneurysms of the sinus of Valsalva in oriental patients. J Thorac Cardiovasc Surg 99:288-298, 1990
7. Munk M, Gatzoulis MA, King DE, et al: Cardiac tamponade and death from intrapericardial rupture of sinus of Valsalva aneurysm. Eur J Cardiothorac Surg 15:100-102, 1999 8. Arora R, Trehan V, Rangasetty UM, et al: Transcatheter closure of ruptured sinus of Valsalva aneurysm. J Interven Cardiol 17:53-58, 2004 9. Zhao SH, Yan CW, Zhu XY, et al: Transcatheter occlusion of the ruptured sinus of Valsalva aneurysm with an Amplatzer duct occluder. Int J Cardiol 129:81-85, 2008 10. Takach TJ, Reul GJ, Duncan JM, et al: Sinus of Valsalva aneurysm or ﬁstula: Management and outcome. Ann Thorac Surg 68: 1573-1577, 1999 11. Cullen S, Somerville J, Redington A: Transcatheter closure of ruptured aneurysm of sinus of Valsalva. Br Heart J 71:479-480, 1994 12. Raslan S, Nanda NC, Lloyd L: Incremental value of live/real time three-dimensional transesophageal echocardiography over the two-dimensional technique in the assessment of sinus of Valsalva aneurysm rupture. Echo 28:918-920, 2011 13. Oh-Icí D, Malergue M, Garot J, et al: Sinus of Valsalva rupture: Percutaneous closure with real-time 3-dimensional echocardiography. J Am Coll Cardiol 56:e31, 2010 14. Chandra S, Vijay SK, Dwivedi SK, et al: Delineation of anatomy of the ruptured sinus of Valsalva with three-dimensional echocardiography: The advantage of the added dimension. Echo 29:E148-E151, 2012 15. Jean WH, Kang TJ, Liu CM, et al: Transcatheter occlusion of ruptured sinus of Valsalva aneurysm guided by three-dimensional transesophageal echocardiography. J Formos Med Assoc 103:948-951, 2004 http://dx.doi.org/10.1053/j.jvca.2013.08.022
Safety and Utility of Noninvasive Ventilation During Deep Sedation for Catheter Ablation of Atrial Fibrillation To the Editor: We read with interest the article by Elkassabany et al, entitled “Anesthetic management of patients undergoing pulmonary vein isolation for treatment of atrial ﬁbrillation using high-frequency jet ventilation.”1 We wish to share our experience in the context of using noninvasive ventilation (NIV) during deep sedation to render the procedure safer and more comfortable for patients undergoing a long procedure that requires motionlessness. This