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Real-Time Three-Dimensional Transesophageal Echocardiography in Multiple-Device Closure of a Ruptured Sinus of Valsalva Aneurysm
LETTERS TO THE EDITOR
Real-Time Three-Dimensional Transesophageal Echocardiography in Multiple-Device Closure of a Ruptured Sinus of Valsalva Aneurysm To the Editor: The role of real-time three-dimensional transesophageal echocardiography (3D TEE) for percutaneous closure of a ruptured sinus of Valsalva aneurysm has been published earlier in this Journal.1 The authors report further substantiates the importance of real-time 3D TEE in the management of complex cardiac interventions, in which it can provide cardiac structural information as well as accurate guidance during the procedure. A 34-year-old man (weight: 57 kg; height: 164; body mass index: 21) with a long-standing history of palpitation and worsening exertional dyspnea (New York Heart Association Class III) was admitted with signs of left ventricular failure. Transthoracic echocardiography (TTE) showed rupture of the sinus of Valsalva (RSOV) and mild aortic regurgitation. The right coronary sinus had ruptured into the right ventricular outflow tract (RVOT), with the aneurysm covering it. The aneurysm was deforming the pulmonary valve in diastole without affecting the pulmonary valve function or producing RVOT obstruction. There were 2 large fenestrations in the sinus of about 8-mm each, along with multiple smaller ones. The mouth of the aneurysm measured 17 mm, and the right coronary artery was in close proximity to the opening of the aneurysm. The right coronary cusp attachment of the aortic valve was at the edge of the mouth of the aneurysm. Percutaneous device closure of the ruptured aneurysm under TEE and fluoroscopy guidance was planned. Under general anesthesia, intraoperative 3D TEE was performed using X7-2t, x MATRIX transducer and Philips IE33 echocardiography machine (KPI Ultrasound, Yorba Linda, CA, USA). 3D TEE confirmed the TTE findings and illustrated clearly the spatial relationship of the defect with the adjacent structures. There was a large 3.4-cm 2.8-cm sinus of Valsalva aneurysm arising from the right sinus of Valsalva, with the mouth of the aneurysm measuring 17 mm. The cardiac intervention was performed using femoral vessels for vascular access, and the first fenestration was closed with a 23/25-mm Occlutech Figulla PFO Occluder (Occlutech GmbH, Jena, Germany). Color Doppler identified the location of the second large fenestration. A guiding catheter was passed through the fenestration and the position confirmed by 3D TEE (Fig 1). A second device (18-mm PFO Amplatzer occluder, St. Jude Medical, Inc. St. Paul, MN, USA] was deployed. 3D TEE further confirmed that the right coronary artery was not encroached on by the devices (Fig 2). After deployment of the devices, their position, as well as the function of the aortic
valve, was confirmed by 3D TEE (Video clip 1) and fluoroscopy. The patient was moved to the intensive care unit for monitoring after tracheal extubation. For achieving immediate anticoagulation following device deployment, unfractionated heparin infusion was started as per the institutional protocol. The patient was discharged after a TTE confirmed satisfactory outcome after the intervention. RSOV is a rare clinical entity, with a preponderance among Asians.2 After the successful transcatheter closure of an RSOV with a Rashkind umbrella by Cullens et al3 in 1994, device closure for RSOV has become popular as an alternative to surgical closure.4 In patients with RSOV, TEE guidance increasingly has been used for supplementing information obtained from fluoroscopy to make device closure safely.5 Currently, 3D TEE has been found to be a valuable tool for pre-procedural assessment of the
Fig 1. Three-dimensional midsophageal aortic valve short-axis view showing the intervention catheter in the second fenestration in the aneurysm and also showing the first device.
Fig 2. Three-dimensional midsophageal aortic valve short-axis showing the preserved right coronary artery as well as confirming the position of the 2 devices. RCA, right coronary artery.
Journal of Cardiothoracic and Vascular Anesthesia, Vol 29, No 4 (August), 2015: pp e45–e50
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LETTERS TO THE EDITOR
defect, providing accurate information regarding the spatial relation of the defect during the procedure, and confirming uncomplicated device deployment.6,7 3D TEE technologies allow real-time imaging at a high spatial resolution, provide accurate tracking of catheters and devices, as well as aid in delineating precise cardiac anatomy during interventional procedures. To avoid leaving behind uncovered residual aneurysm, RSOV defects are closed as far as possible near the aortic end. This practice could result in the encroachment of the device onto the aortic valve. 3D TEE is a valuable tool to monitor this aspect as well as assess the degree of aortic regurgitation. It also is crucial in assessing the anatomic and hemodynamic effects related to aneurysm protrusion into the RVOT before and after device deployment. Device impingement onto the coronary ostia could occur, albeit rarely, and a selective angiogram has been suggested to rule out this possibility.8 Appropriate interrogation of the right coronary artery with 3D TEE could avoid the angiogram, which is fraught with the problem of contrast load, especially in critically ill patients. In this patient, 3D TEE was instrumental in confirming the precise location and dimensions of the defect. Color Doppler identified the residual shunt through the second lesion after the first device was deployed and confirmed the accurate placement of the catheter through the residual fenestration before deployment of the second device. Identification of the course of the right coronary artery by 3D TEE avoided a right coronary angiogram. The aortic valve function could be tracked and the probability of impingement by the devices also was ruled out. 3D TEE allowed safe, effective, and efficient navigation of the devices to the site of the defect while reducing use of fluoroscopy and exposure to contrast. Lastly, 3D TEE confirmed the proper positioning of the 2 devices with a minimal residual shunt. The authors described the successful closure of fenestrations under 3D TEE guidance with 2 devices in a patient with RSOV. Real-time 3D TEE can provide both diagnostic and procedural advantages during cardiac interventions as it is useful in delineating anatomy, guiding catheters, and ensuring closure of defects. 3D TEE is a valuable tool in cardiac interventions as it could improve procedure safety and reduce procedure time and radiation. APPENDIX A. SUPPORTING INFORMATION
Supplementary material cited in this article is available online at doi:10.1053/j.jvca.2014.10.025.
Madan Mohan Maddali, MD* Salim Nasser Al-Maskari, FRCPCH† Abdulla Al-Farqani, MD, MRCPH† Pranav Subbaraya Kandachar, MCh‡ Departments of *Anesthesia †Pediatric Cardiology, and ‡Cardiothoracic Surgery Royal Hospital Muscat, Oman
REFERENCES 1. Chua JH, Methangkool E, Cha CM, et al: The use of real-time three-dimensional transesophageal echocardiography for percutaneous closure of a ruptured sinus of Valsalva aneurysm. J Cardiothorac Vasc Anesth 28:e4-6, 2014 2. 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 3. Cullen S, Somerville J, Redington A: Transcatheter closure of ruptured aneurysm of sinus of Valsalva. Br Heart J 71:479-480, 1994 4. Kerkar PG: Ruptured sinus of Valsalva aneurysm: Yet another hole to plug! Ann Pediatr Cardiol 2:83-84, 2009 5. Sarupria A, Kapoor PM, Makhija N, et al: Trans-esophageal echocardiography: an indispensable guide for transcatheter device closure of ruptured sinus of Valsalva aneurysm. Ann Card Anaesth 15: 156-157, 2012 6. Raslan S, Nanda NC, Lloyd L, et al: 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 7. Vatankulu MA, Tasal A, Erdogan E, et al: The role of threedimensional echocardiography in diagnosis and management of ruptured sinus of Valsalva aneurysm. Echocardiography 30:E260-E262, 2013 8. Guan L, Zhou D, Zhang F, et al: Percutaneous device closure of ruptured sinus of Valsalva aneurysm: a preliminary experience. J Invasive Cardiol 25:492-496, 2013 http://dx.doi.org/10.1053/j.jvca.2014.10.025
Improving the Quality and Safety as Well as Reducing the Cost for Patients Undergoing Cardiac Surgery: Missing Some Issues? To the Editor: In the review by Merry et al,1 the authors have aimed to present the foundation of safety and quality in cardiac surgery and have summarized key points in measuring and effecting the care of the cardiac surgical patient. The article emphasized that the quality of healthcare depends on the interplay of several components, including safety, timelines, efficiency, efficacy, equitability, and patient-centeredness. Teamwork in the perioperative setting is essential to assure harmony in care and the best outcomes and patient/family satisfaction. The cardiac anesthesiologists are well-placed to provide leadership in organizing the elements of perioperative care and promoting improvements in efficiency and safety in a high-performing team. This cohesive and comprehensive study1 did, however, omit some issues relevant to the quality of perioperative care, specifically the function and value of the preoperative evaluation clinic for cardiac surgery, the role of dental assessment before major cardiac surgery, and the effects of positioning of patients in the operating room (OR). Pre-admission clinics (PACs) have been developed to streamline the preoperative assessment by coordinating all aspects of the anesthetic, surgical, medical, nursing, and
Real-Time Three-Dimensional Transesophageal Echocardiography in Multiple-Device Closure of a Ruptured Sinus of Valsalva Aneurysm To the Editor: The role of real-time three-dimensional transesophageal echocardiography (3D TEE) for percutaneous closure of a ruptured sinus of Valsalva aneurysm has been published earlier in this Journal.1 The authors report further substantiates the importance of real-time 3D TEE in the management of complex cardiac interventions, in which it can provide cardiac structural information as well as accurate guidance during the procedure. A 34-year-old man (weight: 57 kg; height: 164; body mass index: 21) with a long-standing history of palpitation and worsening exertional dyspnea (New York Heart Association Class III) was admitted with signs of left ventricular failure. Transthoracic echocardiography (TTE) showed rupture of the sinus of Valsalva (RSOV) and mild aortic regurgitation. The right coronary sinus had ruptured into the right ventricular outflow tract (RVOT), with the aneurysm covering it. The aneurysm was deforming the pulmonary valve in diastole without affecting the pulmonary valve function or producing RVOT obstruction. There were 2 large fenestrations in the sinus of about 8-mm each, along with multiple smaller ones. The mouth of the aneurysm measured 17 mm, and the right coronary artery was in close proximity to the opening of the aneurysm. The right coronary cusp attachment of the aortic valve was at the edge of the mouth of the aneurysm. Percutaneous device closure of the ruptured aneurysm under TEE and fluoroscopy guidance was planned. Under general anesthesia, intraoperative 3D TEE was performed using X7-2t, x MATRIX transducer and Philips IE33 echocardiography machine (KPI Ultrasound, Yorba Linda, CA, USA). 3D TEE confirmed the TTE findings and illustrated clearly the spatial relationship of the defect with the adjacent structures. There was a large 3.4-cm 2.8-cm sinus of Valsalva aneurysm arising from the right sinus of Valsalva, with the mouth of the aneurysm measuring 17 mm. The cardiac intervention was performed using femoral vessels for vascular access, and the first fenestration was closed with a 23/25-mm Occlutech Figulla PFO Occluder (Occlutech GmbH, Jena, Germany). Color Doppler identified the location of the second large fenestration. A guiding catheter was passed through the fenestration and the position confirmed by 3D TEE (Fig 1). A second device (18-mm PFO Amplatzer occluder, St. Jude Medical, Inc. St. Paul, MN, USA] was deployed. 3D TEE further confirmed that the right coronary artery was not encroached on by the devices (Fig 2). After deployment of the devices, their position, as well as the function of the aortic
valve, was confirmed by 3D TEE (Video clip 1) and fluoroscopy. The patient was moved to the intensive care unit for monitoring after tracheal extubation. For achieving immediate anticoagulation following device deployment, unfractionated heparin infusion was started as per the institutional protocol. The patient was discharged after a TTE confirmed satisfactory outcome after the intervention. RSOV is a rare clinical entity, with a preponderance among Asians.2 After the successful transcatheter closure of an RSOV with a Rashkind umbrella by Cullens et al3 in 1994, device closure for RSOV has become popular as an alternative to surgical closure.4 In patients with RSOV, TEE guidance increasingly has been used for supplementing information obtained from fluoroscopy to make device closure safely.5 Currently, 3D TEE has been found to be a valuable tool for pre-procedural assessment of the
Fig 1. Three-dimensional midsophageal aortic valve short-axis view showing the intervention catheter in the second fenestration in the aneurysm and also showing the first device.
Fig 2. Three-dimensional midsophageal aortic valve short-axis showing the preserved right coronary artery as well as confirming the position of the 2 devices. RCA, right coronary artery.
Journal of Cardiothoracic and Vascular Anesthesia, Vol 29, No 4 (August), 2015: pp e45–e50
e45
e46
LETTERS TO THE EDITOR
defect, providing accurate information regarding the spatial relation of the defect during the procedure, and confirming uncomplicated device deployment.6,7 3D TEE technologies allow real-time imaging at a high spatial resolution, provide accurate tracking of catheters and devices, as well as aid in delineating precise cardiac anatomy during interventional procedures. To avoid leaving behind uncovered residual aneurysm, RSOV defects are closed as far as possible near the aortic end. This practice could result in the encroachment of the device onto the aortic valve. 3D TEE is a valuable tool to monitor this aspect as well as assess the degree of aortic regurgitation. It also is crucial in assessing the anatomic and hemodynamic effects related to aneurysm protrusion into the RVOT before and after device deployment. Device impingement onto the coronary ostia could occur, albeit rarely, and a selective angiogram has been suggested to rule out this possibility.8 Appropriate interrogation of the right coronary artery with 3D TEE could avoid the angiogram, which is fraught with the problem of contrast load, especially in critically ill patients. In this patient, 3D TEE was instrumental in confirming the precise location and dimensions of the defect. Color Doppler identified the residual shunt through the second lesion after the first device was deployed and confirmed the accurate placement of the catheter through the residual fenestration before deployment of the second device. Identification of the course of the right coronary artery by 3D TEE avoided a right coronary angiogram. The aortic valve function could be tracked and the probability of impingement by the devices also was ruled out. 3D TEE allowed safe, effective, and efficient navigation of the devices to the site of the defect while reducing use of fluoroscopy and exposure to contrast. Lastly, 3D TEE confirmed the proper positioning of the 2 devices with a minimal residual shunt. The authors described the successful closure of fenestrations under 3D TEE guidance with 2 devices in a patient with RSOV. Real-time 3D TEE can provide both diagnostic and procedural advantages during cardiac interventions as it is useful in delineating anatomy, guiding catheters, and ensuring closure of defects. 3D TEE is a valuable tool in cardiac interventions as it could improve procedure safety and reduce procedure time and radiation. APPENDIX A. SUPPORTING INFORMATION
Supplementary material cited in this article is available online at doi:10.1053/j.jvca.2014.10.025.
Madan Mohan Maddali, MD* Salim Nasser Al-Maskari, FRCPCH† Abdulla Al-Farqani, MD, MRCPH† Pranav Subbaraya Kandachar, MCh‡ Departments of *Anesthesia †Pediatric Cardiology, and ‡Cardiothoracic Surgery Royal Hospital Muscat, Oman
REFERENCES 1. Chua JH, Methangkool E, Cha CM, et al: The use of real-time three-dimensional transesophageal echocardiography for percutaneous closure of a ruptured sinus of Valsalva aneurysm. J Cardiothorac Vasc Anesth 28:e4-6, 2014 2. 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 3. Cullen S, Somerville J, Redington A: Transcatheter closure of ruptured aneurysm of sinus of Valsalva. Br Heart J 71:479-480, 1994 4. Kerkar PG: Ruptured sinus of Valsalva aneurysm: Yet another hole to plug! Ann Pediatr Cardiol 2:83-84, 2009 5. Sarupria A, Kapoor PM, Makhija N, et al: Trans-esophageal echocardiography: an indispensable guide for transcatheter device closure of ruptured sinus of Valsalva aneurysm. Ann Card Anaesth 15: 156-157, 2012 6. Raslan S, Nanda NC, Lloyd L, et al: 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 7. Vatankulu MA, Tasal A, Erdogan E, et al: The role of threedimensional echocardiography in diagnosis and management of ruptured sinus of Valsalva aneurysm. Echocardiography 30:E260-E262, 2013 8. Guan L, Zhou D, Zhang F, et al: Percutaneous device closure of ruptured sinus of Valsalva aneurysm: a preliminary experience. J Invasive Cardiol 25:492-496, 2013 http://dx.doi.org/10.1053/j.jvca.2014.10.025
Improving the Quality and Safety as Well as Reducing the Cost for Patients Undergoing Cardiac Surgery: Missing Some Issues? To the Editor: In the review by Merry et al,1 the authors have aimed to present the foundation of safety and quality in cardiac surgery and have summarized key points in measuring and effecting the care of the cardiac surgical patient. The article emphasized that the quality of healthcare depends on the interplay of several components, including safety, timelines, efficiency, efficacy, equitability, and patient-centeredness. Teamwork in the perioperative setting is essential to assure harmony in care and the best outcomes and patient/family satisfaction. The cardiac anesthesiologists are well-placed to provide leadership in organizing the elements of perioperative care and promoting improvements in efficiency and safety in a high-performing team. This cohesive and comprehensive study1 did, however, omit some issues relevant to the quality of perioperative care, specifically the function and value of the preoperative evaluation clinic for cardiac surgery, the role of dental assessment before major cardiac surgery, and the effects of positioning of patients in the operating room (OR). Pre-admission clinics (PACs) have been developed to streamline the preoperative assessment by coordinating all aspects of the anesthetic, surgical, medical, nursing, and