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Cardiovascular Anesthesia: Echo Didactics & Rounds

Sinus of Valsalva Aneurysm Obstructing the Right Ventricular Outflow Tract

Rosenberger, Peter MD; Cohn, Lawrence H. MD; Fox, John A. MD; Locke, Andrew; Shernan, Stanton K. MD3,7

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doi: 10.1213/01.ane.0000217106.74541.e7
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A 78-yr-old male experienced an episode of shortness of breath and hypotension during hemorrhoid surgery performed under local anesthesia. His medical history was significant for hypercholesterolemia, benign prostate hypertrophy, and a history of gastroesophageal reflux. Subsequent workup revealed a new high-pitched systolic murmur, severe mitral regurgitation (MR), and a Sinus of Valsalva (SVA) aneurysm of the aorta. He was referred for mitral valve surgery and SVA repair. On the morning of surgery, coronary artery catheterization revealed a significant lesion in the left anterior descending coronary artery.

Intraoperative multiplane transesophageal echocardiography (TEE) confirmed the preoperative diagnosis of severe MR. A midesophageal four-chamber TEE view revealed an SVA extending towards the right ventricle (RV) (Fig. 1, above). A midesophageal aortic valve (AV) long axis view of the AV confirmed the presence of an SVA primarily involving the right cusp of the AV (Fig. 1, below; please see video loop available at www.anesthesia-analgesia.org) and trace/mild aortic insufficiency (AI) by color flow Doppler. The TEE probe was advanced to the transgastric depth and the multiplane angle rotated to 20° to obtain a modified transgastric RV inflow view that demonstrated the SVA bulging into the RV outflow tract (RVOT) (Fig. 2, above). Color flow Doppler showed turbulent flow at the level of the SVA bulging into the RVOT. In addition a continuous wave Doppler beam oriented parallel to flow through the RVOT demonstrated a mild obstruction consistent with a peak velocity of 1.8 m/s, corresponding to a calculated peak pressure gradient of 13 mm Hg (Fig. 2).

Figure 1.
Figure 1.:
Above, midesophageal four chamber transesophageal echocardiographic (TEE) view at 0° rotation demonstrating an aneurysm of the right sinus of Valsalva (*) protruding towards the right ventricle (RV). Below, midesophageal aortic valve long-axis TEE view at 125° rotation demonstrating the sinus of Valsalva aneurysm (*) protruding into the right ventricular outflow tract. LV, left ventricle; Ao, aorta.
Figure 2.
Figure 2.:
Above, two-dimensional imaging and color flow Doppler of the right ventricular outflow tract (RVOT) in a modified transgastric right ventricular inflow transesophageal echocardiographic (TEE) view at 20° demonstrating the Sinus of Valsalva aneurysm (SVA) (*) protruding into the RVOT. Below, continuous wave Doppler demonstrating mild RVOT obstruction with turbulent color Doppler flow at the site of the SVA. PV, pulmonic valve.

Surgical exposure of the mitral valve revealed a flail middle scallop (P2), which was repaired and reinforced with a 28-mm Cosgrove ring. The left internal mammary artery was grafted to the left anterior descending coronary artery. The SVA was repaired with a Gore-Tex® Patch measuring 1.5 × 0.5 cm, and the patient was weaned uneventfully from cardiopulmonary bypass. Post-cardiopulmonary bypass TEE showed trace MR, confirmed the repaired SVA, persistent trace AI, and an RVOT that was free of anatomic and functional obstruction. The patient had an uneventful postoperative course.

SVA is relatively uncommon with an incidence of 0.14%-0.23% (1). Frequently a bicuspid AV and AI are associated with SVA (2). Complications of this entity often diagnosed by echocardiography include rupture of the aneurysm into one of the cardiac chambers, cardiac tamponade, endocarditis, and myocardial infarction. In the presented case, intraoperative TEE confirmed the preoperative diagnosis of a SVA, and revealed previously unknown RVOT obstruction, a rare phenomenon associated with congenital SVA (3). After surgical correction, the absence of anatomic or functional abnormalities of the AV and the RVOT were confirmed by intraoperative TEE.

References

1. Goldberg N, Krasnow N. Sinus of Valsalva aneurysms. Clin Cardiol 1990;13:831–6.
2. Edwards JE, Burchell HB. The pathological anatomy of deficiencies between the aortic root and the heart, including aortic sinus aneurysms. Thorax 1957;12:125–39.
3. Ring WS. Congenital heart surgery nomenclature and database project: aortic aneurysm, sinus of Valsalva aneurysm, and aortic dissection. Ann Thorac Surg 2000;69:S147–63.
© 2006 International Anethesia Research Society