Ruptured sinus of valsalva aneurysm - a rare cause of heart failure, challenges in transcatheter closure and mid-term outcomes
Authors: Cecily Mary Majella J , Gnanavelu Ganesan G , Swaminathan N , Justin Paul G , Karthikeyan G 
Published: November 2023

Abstract

Introduction
The ruptured sinus of valsalva aneurysm (RSOV) portends an important cause for acute heart failure. Closure of the defect either percutaneously or surgically is of paramount importance. We report 38 cases of RSOV who presented with cardiac failure, among which 22 cases were selected and amenable for transcatheter closure.Transcatheter closure of RSOV has favorable outcomes in the short-term and mid-term follow-up.

Purpose of the study
To assess the short-term and midterm outcomes of transcatheter closure of RSOV.

Methods
All patients who presented with cardiac failure and diagnosed as RSOV by transthoracic echo, from June 2012 to Dec 2022 were included in the study.Age group was between 12 to 73 years.All the 38subjects (Males -24, Females -14) of RSOV, underwent trans esophageal echo (TEE). 22 casesere selected for device closure..The subjects were classified according to New York Heart Association (NYHA) class III - 82%, class IV- 18 %. Size of the defect was measured at the aortic end by TEE and aortogram, and upsized by 2-4 mm from the aortic end. In 21 subjects, the RSOV was entered from the aorta, and an arterio-venous loop was created, and various devices, duct occluders and atrial septal occluder and muscular ventricular septal occluder were used to close the defects. In one patient the RSOV was acquired following surgical closure of perimembranous ventricular septal defect, which was small measuring 3mm at aortic end and hence closed using 4/6 ADO II without forming the arterio-venous loop. Patients were followed up post discharge 1 week, 1 month, 3 months, 6 months, 1 year and every year till 10 years by clinical examination, ECG, and transthoracic echo.

Results
All 22 patients who underwent successful RSOV device closure improved to NYHA functional class II within 48 hours post procedure and to functional class I at 3 months of follow-up. 3 female patients underwent successful pregnancy and labor after RSOV device closure without any intrapartum or postpartum complications. Two patients had trivial aortic regurgitation pre-procedure remained the same status on follow up post-procedure. One patient developed) severe right coronary artery spasm, due to inadvertent RCA cannulation while crossing the defect, which cleared with nasal oxygen and intracoronary nitroglycerine. A minimal residual shunt was found in 2 patients which gradually disappeared at 6 months. One patient with a large defect (15mm), an atrial septal occluder - 20mm was deployed, developed hemolysis, and hence referred for surgery. Transient global LV systolic dysfunction was present in two patients due to afterload mismatch, whose LV function recovered after 72 hours.

Conclusion
Percutaneous device closure of RSOV is a feasible and an enticing alternative to surgery in selected patients, as inferred by the short and mid-term outcomes. The age group 12 to 73 years encompasses the youngest and oldest age group yet reported.PROFILE OF RSOV DEVICE CLOSURE CASESRSOV CASE SELECTION AND OUTCOMES