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Asian Cardiovasc Thorac Ann 2005;13:298
© 2005 Asia Publishing EXchange Ltd

LETTER TO EDITOR

Incidental Dilatation of Ruptured Sinus of Valsalva Aneurysm During Catheterization

Alexander S Geha, MD, Malek G Massad, MD, Cimenga Tshibaka, MD

The Division of Cardiothoracic Surgery, The University of Illinois at Chicago, Chicago, Illinois, USA

We write to express to the readers of the journal a word of caution regarding a clinical situation that we encountered recently.

A 25-year-old woman presented with a continuous murmur and a thrill over the left sternal border. An echocardiogram showed a fistulous connection from the aorta to the right ventricle (RV). Catheterization showed a large step-up in oxygen saturation in the right atrium (RA) 87% and RV 91%. The pulmonary to systemic flow ratio was 3.8. There was pulmonary hypertension (58/20 mm Hg), RV hypertension (58/28 mm Hg), RA hypertension (36 mm Hg) and severe tricuspid regurgitation. The RV end diastolic pressure was higher than the left ventricular (LV) end diastolic pressure (28 vs 15 mm Hg). During catheterization of the LV retrogradely through the aortic valve, the pigtail catheter tip slipped through the coronary Sinus of Valsalva aneurysm into the RV and was immediately withdrawn.

Following catheterization, the patient developed severe hemodynamic instability and cardiac arrest from which she was resuscitated. She was taken to the operating room where hypothermic extracorporeal circulation was rapidly instituted after heparinization and cannulation of the aorta and cavae. The right heart immediately decompressed. After aortic cross-clamping and retrograde cardioplegia, an aortotomy showed a large "wind-sock" communication, 15 mm in diameter, between the noncoronary sinus of Valsalva, close to the commissure with the right coronary sinus, and the RV. This was pulled back into the sinus of Valsalva. Excess tissue was excised and the base was repaired with interrupted mattress sutures of 5-0 polypropylene buttressed with Teflon pledgets on both sides. After closure of the aortotomy and warm blood cardioplegia, the aortic cross-clamp was removed. The patient was then weaned off cardiopulmonary bypass following a period of reperfusion. An intraoperative transesophageal echocardiogram showed a competent aortic valve with no further evidence of communication to the RV. Following repair, the RA pressure was 8 mm Hg. The RV distention also regressed. After a period of uncertainty as to her neurological and renal status, the patient made a good recovery of her neurologic function but required dialysis due to compromised renal function from low organ perfusion.

We believe that the state of cardiogenic shock was triggered by incidental acute dilatation by the pigtail catheter of the ruptured windsock of the sinus of Valsalva aneurysm into an already volume-overloaded RV.

We would like to bring this to the attention of the reader with a word of caution when attempting to instrument the aortic root region for fear of cannulating the fistulous tract and causing acute right heart distention. Immediate intervention in this setting is mandatory to repair the defect and reverse the state of hemodynamic collapse





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Malek G Massad
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