An Unusual Cause for RSOV Device Closure Complication

This video discusses the management of a complication of device closure for ruptured sinus of Valsalva.

The patient was a twenty-seven-year-old man. He was evaluated for a sudden onset of palpitations for three months and diagnosed with a ruptured sinus of Valsalva and right coronary cusp opening into the right ventricular outflow tract by echocardiography. He was planned for device closure for the ruptured sinus of Valslava (RSOV). 

The procedure was completed using a 14/16 mm PDA occluder. There was no leak across the device in the check angiography. The patient did well in the post-procedure period and was discharged home. However, after ten days of device closure he developed hemoglobinuria. A repeat echocardiogram showed no leak across the RSOV closure device, but the 3 mm VSD jet was hitting the device, causing hemolysis. The patient was planned for device closure of the VSD, but it was not possible, as the VSD was partially closed by the RSOV device. He was planned for surgical closure of VSD in view of persistent hemolysis. His ECG was unremarkable and a chest X-ray showed the RSOV device in situ. An echocardiogram revealed the small outlet VSD with left to right shunt.

To begin the procedure, a median sternotomy was performed under general anesthesia. The pericardium was opened and cardiopulmonary bypass was initiated using aortic, SVC, and IVC cannulation. The heart was arrested using antegrade cardioplegia after application of an aortic cross-clamp. The heart was vented via the patent foramen ovale. The aorta was then opened and the device was visualized. 

Next, the main pulmonary artery was opened longitudinally and the RVOT side of the device was visualized. The VSD was partially occluded by the device. As there was no margin to take sutures on the device side for VSD closure, it was planned to remove the device. The device was separated from the right coronary sinus from the aortic and RVOT side and was removed. The aortic end of the RSOV opening was closed using a glutaraldehyde fixed pericardial patch with interrupted pledgeted Prolene sutures. From the RVOT side, the VSD and the RSOV were closed together using a single glutaraldehyde fixed pericardial patch with interrupted pledgeted Prolene sutures. The aorta and right atrium were closed in two layers, and the pulmonary artery was augmented with a pericardial patch. 

The patient was weaned off bypass smoothly and hemostasis was achieved. Intraoperative TEE showed no shunt across the RSOV and VSD patch, and there was no aortic regurgitation. Protamine was started and sequential decannulation was done. The chest was then closed in a routine fashion. The patient’s hemolysis settled, and his urine was of normal color. He was discharged on postoperative day seven and was doing well in the last follow up at one month.

The authors concluded that in the presence of RSOV, the VSD may be masked or underestimated because of the partial or complete obstruction of VSD by RSOV tissue, or the flow across the VSD may be missed in Dopler echocardiography because of the flow of the RSOV to RVOT. So before RSOV device closure, presence of VSD should be ruled out, as RSOV with VSD is better managed surgically than by percutaneous techniques.

References

1. Kerkar PG. Ruptured sinus of Valsalva aneurysm: Yet another hole to plug! Ann Pediatr Cardiol. 2009 Jan;2(1):83-4. doi: 10.4103/0974-2069.52818. PMID: 20300276; PMCID: PMC2840774.
2. Mahimarangaiah J, Chandra S, Subramanian A, Srinivasa KH, Usha MK, Manjunath CN. Transcatheter closure of ruptured sinus of Valsalva: Different techniques and mid-term follow-up. Catheter Cardiovasc Interv. 2016 Feb 15;87(3):516-22. doi: 10.1002/ccd.26107. Epub 2015 Aug 10. PMID: 26255646.
3. Prafulla G. Kerkar, Charan P. Lanjewar, Nidheesh Mishra, Prasanna Nyayadhish, Isaac Mammen, Transcatheter closure of ruptured sinus of Valsalva aneurysm using the Amplatzer duct occluder: immediate results and mid-term follow-up, European Heart Journal, Volume 31, Issue 23, December 2010, Pages 2881–2887, https://doi.org/10.1093/eurheartj/ehq323

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