Sinus of Valsalva Aneurysm? Ronald A. Kahn, MD,* and Farzan Filsoufi, MD†
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HE PATIENT WAS a 29-year-old man with a past medical history significant for hypertension, diabetes mellitus, a cerebral vascular accident, and end-stage renal disease on hemodiFrom the Departments of *Anesthesiology and †Cardiothoracic Surgery, The Mount Sinai Medical Center, New York, NY. Address reprint requests to Ronald A. Kahn, MD, Department of Anesthesiology, Box 1010, The Mount Sinai Medical Center, One Gustave L. Levy Place, New York, NY 10029. E-mail:
[email protected] © 2006 Elsevier Inc. All rights reserved. 1053-0770/06/2002-0030$32.00/0 doi:10.1053/j.jvca.2005.12.006 Key words: transesophageal echocardiography, mitral valve, endocarditis, aortic root abscess
Fig 1.
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alysis who presented for an aortic root reconstruction with coronary artery reimplantation (Bentall) and mitral valve repair. The perioperative transesophageal echocardiograms are presented (Figs 1-5 and Videos 1-5 [supplementary videos accompanying this article are available online]). The midesophageal long-axis view revealed an echo-free region in the anterior and leftward aspect of the proximal ascending aorta (Fig 1, Video 1). This region moved distally during systole (Fig 1A) and proximally into the left ventricular outflow tract during diastole (Fig 1B). The midesophageal aortic valve short axis view is presented in Figure 2 and Video 2. The anterior mitral valve leaflet is imaged in Figures 3 and 4 and Videos 3 and 4. The right atrium is imaged in Figure 5 and Video 5. What is the diagnosis?
(A) Midesophageal long-axis during systole. (B) Midesophageal long-axis during diastole.
Journal of Cardiothoracic and Vascular Anesthesia, Vol 20, No 2 (April), 2006: pp 280-283
SINUS OF VALSALVA ANEURYSM?
Fig 2.
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Midesophageal aortic valve short-axis.
Fig 4. (A) Midesophageal 4-chamber view (with mild anterior flexion). (B) Closeup of the mitral valve with color-flow Doppler.
DIAGNOSIS: AORTIC ROOT ABSCESS WITH A KISSING LESION OF THE MITRAL VALVE (RIGHT ATRIAL THROMBUS)
Fig 3. (A) Midesophageal commissural view (B) with color-flow Doppler.
The patient presented with infectious endocarditis. Preoperative echocardiography revealed a large thrombus attached to the patient’s dialysis catheter, which was the presumed site of the infection (Fig 5, Video 5). As seen in Figure 2 (Video 1 and 2), there was severe distortion of the aortic valve by this left-sided aortic root abscess without involvement of the left atrium or the right ventricular outflow tract. This aortic valve distortion resulted in severe aortic insufficiency. The longitudinal extent of the aortic root abscess is shown in Figure 1 and Video 1; it extended from the aortic root to the sinotubular junction. The aortic regurgitation resulted in a kissing lesion of the A2 segment of the mitral valve with resultant leaflet abscess and perforation and incompetence (type 1 Carpentier’s functional classification). The A2 segment of the mitral valve is imaged in Figures 3 and 4 and Videos 3 and 4. The patient underwent a Bentall procedure, mitral valve repair, and right atrial thrombectomy.
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KAHN AND FILSOUFI
Fig 5.
Midesophageal bicaval view.
Paravalvular abscess formation is an advanced form of acute endocarditis, where the infection extends beyond the confines of the aortic valve. When the native aortic valve is involved, the incidence of aortic root abscess has been reported to be between 30% to 40%.1,2 The most common responsible microorganisms are staphylococcus (both S epidermidis and S aureus), enterococcus, and streptococcus.3 The extension of abscesses is influenced by their origin. Abscesses involving the noncoronary cusp tend to extend toward the atrioventricular node and mitral valve annulus; alternatively, they may extend to the right atrium with the creation of an aortic-right atrial fistula. Abscesses involving the right or left coronary cusps extend beneath the main pulmonary artery or into the interventricular septum.4 Aortic valve endocarditis giving rise to aortic root abscess commonly extend into the mitral/aortic intervalvular fibrosa.5 Infectious endocarditis may extend to the mitral valve via several mechanisms. The “per continuitatem” or local metastatic form leads to severe destructive endocarditis. The infectious process extends to the intervalvular fibrous skeleton and to the mitral annulus and anterior mitral valve leaflet.6 The mitral annular involvement may vary from simple localized annular abscess formation to a large aneurysmatic abscess with or without rupture into the cardiac
chambers or extension into the adjacent structures disrupting the ventricular-aortic continuity and the aortomitral fibrous trigone.7-9 Mitral valve involvement of this endocardial abscess may result in significant mitral valve dysfunction.10 Alternatively, the diastolic jet of aortic regurgitation because of the primary endocarditis can produce a secondary lesion on the ventricular surface of the anterior leaflet of the mitral valve.11,12 This “kissing lesion” may present as a vegetation, leaflet abscess, or perforation. Although surgical management plays a central role in the treatment of aortic root abscesses, the mortality rate is high.13 Although some authors have recommended the use of allograft valves to be more effective for active infective endocarditis, it is possible that the choice of type of valve is not as important as the radical resection of the abscess.14-16 Although it is possible that the sensitivity of newly implanted valves is associated with the fabric used to produce the valve prostheses, radical resection of the abscess and left ventricular-aortic reconstruction may increase the probability of eradicating the infection and may enable the use of a mechanical prosthesis. Homograft reconstruction of the left ventricular outflow tract for the treatment of aortic root abscess carries an operative mortality of 9.3% for elective/ urgent and 14.3% for emergency surgery.3 If patients required aortic root and mitral valve reconstruction, operative mortality rates may be as high as 29%. The most potent independent risk factors for death were severe aortic root destruction (odds ratio [OR] 4.65, confidence interval [CI] 1.22-17.1, p ⫽ 0.0159), septic shock (OR 3.44, CI 0.85-13.9, p ⫽ .07), pre- and postoperative ejection fraction less than 40% (OR 2.5, CI 1.04-1.2, p ⫽ 0.0027 and OR 2.7, CI 1.02-1.14, p ⫽ 0.07, respectively), and dilated left ventricle (⬎65 mm) (OR 2.0, CI 1.14-1.22, p ⫽ 0.0007).6 In this report, TEE provided important information in the delineation of aortic root abscesses. This utility has been confirmed by others.17 TEE may be used to accurately delineate size and extent of the abscess as well as involvement and communications with adjacent structures. The mechanism and severity of both aortic and mitral regurgitation may be evaluated. The precise determination of valvular lesions (annular abscess, leaflet perforation) is particularly important to identify the underlying etiology of the valvular disease.
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