Midterm outcomes and durability of sinus segment preservation compared with root replacement for acute type A aortic dissection.

OBJECTIVE: The durability of root repair for acute type A aortic dissection is not well studied in the context of aortic insufficiency and stability of the sinuses of Valsalva. We compared clinical and functional outcomes in patients undergoing root repair and replacement for acute type A aortic dissection. METHODS: Of 716 patients undergoing surgery for acute type A aortic dissection, 585 (81.7%) underwent root repair and 131 (18.3%) underwent root replacement. Survival, cumulative incidence of reoperation, aortic insufficiency, and sinuses of Valsalva dilation were compared between the 2 groups. RESULTS: Survival at 1, 5, and 10 years was 84.1% versus 77.3%, 70.8% versus 69.2%, 57.6% versus 58.0% in the root repair and replacement groups, respectively (P = .69). Cumulative incidence of reoperation at 1, 5, and 10 years was 0.0% versus 0.8%, 1.4% versus 3.8%, and 3.4% versus 8.6% in the root repair and root replacement groups, respectively (P = .011). Multivariable Cox regression identified sinuses of Valsalva diameter 45 mm or more as a risk factor for proximal aortic reoperation (hazard ratio, 9.06; 95% confidence interval, 1.26-65.24). In a repeated-measures, linear, mixed-effects model, root replacement was associated with smaller follow-up of sinuses of Valsalva dimensions (ß = -0.66, P < .001). In an ordinal longitudinal mixed model, root replacement was associated with lower severity of postoperative aortic insufficiency (ß = -3.10, P < .001). CONCLUSIONS: Survival is similar, but the incidence of aortic insufficiency and root dilation may be greater after root repair compared with root replacement for acute type A aortic dissection.

Ruptured sinus of valsalva aneurysm presenting as syncope and hypotension: a case report.

BACKGROUND: Unruptured sinus of valsalva aneurysm (SOVA) are typically asymptomatic, and hence can be easily ignored. Ruptured sinus of valsalva aneurysm (RSOVA) usually protrude into the right atrium or ventricular. However, in this case, the RSOVA protruded into the space between the right atrium and the visceral pericardium leading to compression of the right proximal coronary artery. Very few such cases have been reported till date. CASE PRESENTATION: We describe a case of ruptured right SOVA in a 61-year-old man with syncope and persistent hypotension. At the beginning, considered the markedly elevated troponin, acute myocardial infarction was considered. However, emergency coronary angiography unexpectedly revealed a large external mass compressed right coronary artery (RCA) resulting in severe proximal stenosis. Then, aorta computed tomography angiography (CTA) and urgent surgery confirmed that the ruptured right SOVA led to external compression of the right proximal coronary artery. Finally, ruptured right SOVA repair and RCA reconstruction were successfully performed, and the patient was discharged with no residual symptoms. CONCLUSIONS: It is very important to be vigilant about the existence of SOVA. RSOVA should be suspected in a patient presenting with acute hemodynamic compromise, and echocardiography should be immediately performed. Moreover, it is very important to achieve dynamic monitoring by using cardiac color ultrasound. Definitive diagnosis often requires cardiac catheterization, and an aortogram should be performed unless endocarditis is suspected.

Ruptured sinus of Valsalva aneurysm: An uncommon presentation of shock to the pediatric emergency department.

This case report describes a rare etiology of cardiogenic shock, particularly in the pediatric population. A healthy 17 year old male presents from an outside hospital in undifferentiated shock requiring vasopressor support. Ruptured sinus of Valsalva aneurysm was diagnosed by echocardiogram and the patient went emergently to the operating room for surgical repair. We discuss the anatomy, incidence, and risk factors for sinus of Valsalva aneurysms, along with the range of clinical presentations and Emergency Department management of symptomatic rupture of sinus of Valsalva aneurysms.

Utility of ECG-Gated CTA for Detecting and Classifying Coronary Artery Involvement in Patients With Type A Aortic Dissection and Sinus of Valsalva Involvement.

BACKGROUND. Extension of type A aortic dissection (TAAD) from the sinus of Valsalva (SV) into the coronary arteries is associated with a poor prognosis and requires direct coronary repair or coronary artery bypass grafting (CABG) depending on the extent of involvement. OBJECTIVE. The purpose of this study was to assess the diagnostic performance of ECG-gated aortic CTA with surgical findings as the reference for detection and classification of coronary artery involvement in patients with TAAD involving the SV. METHODS. This retrospective study included 112 patients who underwent preoperative ECG-gated aortic CTA that showed TAAD with SV involvement. Two radiologists independently reviewed CTA images for right coronary artery (RCA) and left coronary artery (LCA) involvement. Involvement was classified according to a previously described system as type A (coronary ostial dissection), B (dissection with coronary false channel), or C (complete detachment from aortic root with dissection encircling the coronary artery). The diagnostic performance of CTA was calculated with surgical findings as the reference; interreader agreement was assessed; and surgical interventions were summarized. RESULTS. At surgery, the RCA was uninvolved in 33 patients and had type A involvement in 45, type B involvement in 19, and type C involvement in 15 patients. The LCA was uninvolved in 70 patients and had type A involvement in 34 patients, type B involvement in eight patients, and type C involvement in no patient. For the two readers, sensitivity in making the diagnosis in the RCA was 86.7% and 91.1% for type A, 79.0% and 89.5% for type B, 86.7% and 93.3% for type C, and 97.5% and 98.7% for any involvement. Sensitivity for the LCA was 85.3% and 91.2% for type A, 87.5% and 100% for type B, and 100% for any involvement. Specificity for the RCA was 94.0% and 97.0% for type A, 95.7% and 96.7% for type B, 96.9% and 96.9% for type C, and 93.9% and 97.0% for any involvement. Specificity for the LCA was 96.2% and 98.7% for type A, 96.2% and 97.1% for type B, and 97.1% and 98.6% for any involvement. Interreader agreement for types of involvement ranged from a kappa value of 0.85 to 0.96. The most common interventions were aortic repair for SV involvement alone (55.7-63.6%), coronary artery repair for types A and B involvement (53.3-87.5%), and CABG for type C involvement (86.7%). CONCLUSION. ECG-gated CTA has high diagnostic performance in the detection and classification of coronary involvement in TAAD with SV involvement. CLINICAL IMPACT. CTA findings may help guide presurgical planning for patients with TAAD.

Quantitative perfusion-CMR is significantly influenced by the placement of the arterial input function.

The aim of this study is to provide a systematic assessment of the influence of the position on the arterial input function (AIF) for perfusion quantification. In 39 patients with a wide range of left ventricular function the AIF was determined using a diluted contrast bolus of a cardiac magnetic resonance imaging in three left ventricular levels (basal, mid, apex) as well as aortic sinus (AoS). Time to peak signal intensities, baseline corrected peak signal intensity and upslopes were determined and compared to those obtained in the AoS. The error induced by sampling the AIF in a position different to the AoS was determined by Fermi deconvolution. The time to peak signal intensity was strongly correlated (r2 > 0.9) for all positions with a systematic earlier arrival in the basal (- 2153 ± 818 ms), the mid (- 1429 ± 928 ms) and the apical slice (- 450 ± 739 ms) relative to the AoS (all p < 0.001). Peak signal intensity as well as upslopes were strongly correlated (r2 > 0.9 for both) for all positions with a systematic overestimation in all positions relative to the AoS (all p < 0.001 and all p < 0.05). Differences between the positions were more pronounced for patients with reduced ejection fraction. The error of averaged MBF quantification was 8%, 13% and 27% for the base, mid and apex. The location of the AIF significantly influences core parameters for perfusion quantification with a systematic and ejection fraction dependent error. Full quantification should be based on obtaining the AIF as close as possible to the myocardium to minimize these errors.

Resolution of post-anaesthesia aortic regurgitation by repair of a ruptured sinus of Valsalva aneurysm: 5 case reports.

BACKGROUND: Ruptured sinus of Valsalva aneurysm (SVA) is a rare cardiovascular disease in which some patients exhibit aortic valve insufficiency. SVA repair and valve replacement are usually required for treatment. Here, we report 5 cases of ruptured SVA with severe post-anaesthesia aortic regurgitation (AR). To the best of our knowledge, this is the first report of ruptured SVA with severe post-anaesthesia AR. CASE PRESENTATION: From 2018 to 2020, there were 5 cases of ruptured SVA with severe AR after anaesthesia in our hospital. The main symptoms were palpitation and shortness of breath. Transthoracic echocardiography (TTE) with colour-flow Doppler showed ruptured aortic sinus aneurysms without AR. Post-anaesthesia echocardiography showed severe AR. Direct patch closure of the ruptured aneurysm resolved the left-to-right shunt and AR, and the aortic valve was not replaced. CONCLUSIONS: Post-anaesthesia AR without obvious structural defects may occur in patients with ruptured SVAs. Valve replacement may not be necessary.

Effect of Left and Right Coronary Flow Waveforms on Aortic Sinus Hemodynamics and Leaflet Shear Stress: Correlation with Calcification Locations.

Coronary flow induces hemodynamic alterations in the aortic sinus region. The objectives of this study are to: (1) investigate the differences among sinus hemodynamics and leaflet wall shear stresses engendered by the left versus right versus non-coronary flow and (2) correlate respective wall shear stresses with leaflet calcification in patients. A left heart simulator flow loop with a tunable coronary circuit provided physiological coronary flow waveforms corresponding to the left coronary cusp case (LCC), right coronary cusp case (RCC), and non-coronary cusp case (NCC). High spatio-temporal resolution particle image velocimetry was conducted to quantify leaflet wall shear stress and sinus vorticity fields and to measure aortic leaflet tip kinematics. Thirty-one patients with severe calcific aortic valve disease were segmented from CT data for the calcific volumes in their respective left, right, and non-coronary cusps. Leaflet tip position during systole shows the RCC has a wider leaflet opening compared to LCC and NCC. Velocity and vorticity fields combined with leaflet position data show that sinus vorticity is diminished (peak ~ 43 s-1) in the LCC while RCC and NCC maintain high vorticity (~ 1200 and ~ 950 s-1 respectively). WSS magnitudes greater than 0.3 Pa show 20 and 81% greater occurrences in the LCC and RCC respectively compared to NCC. Significant differences [X2 (2, n = 31) = 7.31, p = 0.0258] between the calcification levels in each cusp of the patient population. Coronary flow differences between LCC, RCC, and NCC show significant impact on leaflet kinematics and sinus flow hemodynamics. Clinical data correlations of the coronary flow cases indicate the left coronary cusp has a higher likelihood of calcification compared to the right.

Reliability of non-contrast magnetic resonance angiography-derived aortic diameters in Marfan patients: comparison of inner vs. outer vessel wall measurements.

Aortic diameter measurements play a crucial role for the indication of aortic root surgery in Marfan patients. However, for magnetic resonance angiography (MRA)-derived measurements, there is no consensus on whether the aortic wall should be included or excluded in the aortic diameter. The purpose of this retrospective study was to compare the reliability of non-contrast bright blood MRA aortic inner-to-inner and outer-to-outer edge measurements in patients with Marfan syndrome. Forty Marfan patients underwent ECG-gated balanced steady-state free-precession MRA of the aorta at 1.5 T. Two readers independently performed inner and outer measurements at different aortic levels. They rated the image quality of the delineation of both inner and outer vessel wall edges on a four-point scale. MRA-derived diameters of the sinuses of Valsalva were compared with echocardiography-derived diameters. Aortic vessel wall delineation score was rated higher at all levels for inner than for outer vessel walls (p < 0.001). Inter- and intraobserver variances of aortic measurements were smaller for inner-to-inner measurements at the sinuses of Valsalva, sinotubular junction and ascending aorta (p < 0.03). There was a difference of 1.1 ± 2.3 mm for inner MRA measurements (p = 0.014) and 6.9 ± 3.1 mm for outer MRA measurements (p < 0.001) when compared to echocardiographic leading-edge measurements. Inner-to-inner vessel wall diameter measurements in non-contrast bright blood MRA provide more reliable diameters when compared to outer-to-outer vessel wall measurements of the aortic root. Therefore, we propose to rely on inner rather than outer aortic wall measurements in non-contrast-MRA when monitoring aortic diameters in patients with Marfan syndrome.

Sinus Hemodynamics After Transcatheter Aortic Valve in Transcatheter Aortic Valve.

BACKGROUND: This study evaluated the effect of transcatheter aortic valve (TAV)-in-TAV on sinus hemodynamics and washout. With TAV becoming the standard procedure for aortic valve replacement and with the limited valve durability, a second intervention is necessary (TAV-in-TAV) after first TAV failure. METHODS: Six arrangements of TAV-in-TAV were chosen for this study as follows: (1) Evolut 23 (Medtronic, Minneapolis, MN) in Evolut 26, (2) Evolut 23 in SAPIEN 3 23 (Edwards Lifesciences, Irvine, CA), (3) Evolut 26 in Evolut 26, (4) Evolut 26 in SAPIEN 23, (5) SAPIEN 3 23 in Evolut 26, and (6) SAPIEN 3 23 in SAPIEN 3 23. These TAV-in-TAV configurations were assessed in a pulse duplicator. Particle image velocimetry was performed. RESULTS: During systole, (1) the highest velocity was found with SAPIEN-in-SAPIEN (0.7 m/s) and the lowest was with Evolut 26-in-Evolut 26 (0.2 m/s); (2) the highest shear stress magnitude near the leaflet was with Evolut 23-in-SAPIEN (1.45 Pa) and the lowest was with Evolut 26-in-Evolut 26 (0.55 Pa); and (3) washout was almost equal in all sinuses of these cases (<2.5 cycles). CONCLUSIONS: This study shows that TAV-in-TAV is highly dependent on the valve that is originally implanted and the valve to be implanted. Washout is not significantly degraded after TAV-in-TAV compared with valve-in-valve and TAV replacement. Further studies are needed to optimize valve size and selection.

Acute rupture of a sinus of Valsalva aneurysm into the right atrium: a case report and a narrative review.

BACKGROUND: Sinus of Valsalva aneurysm (SVA) is a rare cardiac anomaly which has potential for spontaneous rupture into other cardiac chambers or the pericardial space (depending on its location). A ruptured SVA has a very poor prognosis with high morbidity and mortality. The development of a shunt between the sinus of Valsalva and right-sided cardiac chambers results in a continuous murmur on examination. Our case report is a case of SVA rupture into the right atrium. CASE PRESENTATION: In this case report, we describe a 23-year-old patient with an acute onset of chest pain, shortness of breath, palpitations and dizziness starting 2 days prior to presentation to the emergency department. The patient was initially treated for presumed pulmonary embolism overnight while awaiting CTPA the next morning. However, further examination by the inpatient medical team demonstrated a continuous machinery cardiac murmur. Subsequent echocardiography demonstrated an acutely ruptured SVA with shunting to the right atrium. Emergency surgical repair resulted in an excellent outcome for the patient. CONCLUSION: A thorough clinical history and physical examination is the cornerstone of all medical encounters. An SVA could be asymptomatic until acute rupture. Echocardiography is the preferred initial diagnostic tool. Additional imaging techniques can be used to confirm the diagnosis. In cases of rupture, prognosis is poor and surgical repair is always required.

Left sinus of Valsalva-Electroanatomic basis and outcomes with ablation for outflow tract arrhythmias.

INTRODUCTION: The ablation of outflow tract premature ventricular contractions (PVCs) is generally safe and effective. In some patients, successful ablation sites may not correlate with the earliest activation. We sought to evaluate mechanistic and anatomic relevance of the region below the left sinus of Valsalva in variable morphology outflow tract ventricular arrhythmias. METHODS: PVC cases where ablation was in the region inferior to the left sinus of Valsalva were identified. Procedural and demographic information and long-term outcomes were obtained. Cadaver dissections to evaluate regional anatomy were done as well. RESULTS: A total of 51 cases were included (age 53 ± 10; 37 [73%] males). Ablation was done for high PVC burden (>20%; mean 27% ± 8%) and presence of symptoms (73%) or ejection fraction less than 50% (78%). QRS morphology included either R wave (8; 16%), Rs (9; 18%), or rS (67%) in lead I, no precordial transition (40; 78%), V2 transition, (7; 14%), or V3 transition (4; 8%). In 31 (61%), the site just below the left coronary cusp was the earliest site, while the remainder had another site earlier. Ablation was acutely successful in 50 of 51 (98%). After 3 months, success was noted in 48 of 51 (94%). In two patients, repeat ablation in the same region resulted in durable suppression. CONCLUSION: The cases presented emphasize the importance of a region centered below the left sinus of Valsalva, where multivariable morphology QRS may be successfully ablated. Consideration of mapping and ablation even when signals are late in this region may be warranted in previously failed ablation attempts or first-line evaluation.

Recanalization of an atretic intramural left main coronary artery after bypass surgery in a pediatric patient with anomalous aortic origin of the left main coronary artery arising from the right sinus of Valsalva.

We report a pediatric patient with nonatherosclerotic chronic total occlusion (CTO) of the left main coronary artery (LMCA) leading to complete LMCA atresia which was successfully recanalized via retrograde techniques through a previous internal mammary bypass graft. After the CTO was treated, the artery was found to be anomalous off the right cusp with an intramural coarse and slit-like orifice. The patient's ischemic symptoms resolved after Percutaneous Coronary Intervention (PCI), and she has continued to do well.

Comparison of the geometry of the left ventricle outflow tract, the aortic root and the ascending aorta in patients with severe tricuspid aortic stenosis versus healthy controls.

The purpose of this study was to assess by multislice computed tomography (MSCT) imaging geometry of the ascending aorta, the aortic root, the aortic annulus and the left ventricle outflow tract (LVOT) in aortic stenosis (AS) patients, to compare aortic root morphology in patients with AS with healthy controls and to evaluate sex differences. Fifty patients with severe AS and 50 age- and gender-matched controls who underwent MSCT were included in the study. The dimensions of the LVOT, the aortic annulus, the aortic root, the ascending aorta, and the volume of the aortic root were retrospectively assessed and a comparison was made between patients with severe tricuspid AS and controls. Patients with tricuspid AS in comparison with controls had smaller dimensions of the sinus of Valsalva resulting in reduction of the aortic root volume, whereas the dimensions of the other structures were comparable. MSCT revealed larger annular, LVOT and the sinus of Valsalva dimensions and the aortic root volume in men than women. Men with AS differed from healthy men only in regard to the dimensions of the sinus of Valsalva, while women showed significant differences also in the LVOT, and the aortic annulus. MSCT showed accurately aortic root remodeling in tricuspid AS patients and indentified sex-dependent differences. Women with tricuspid AS differ from healthy women more than men did. A high degree of the variability in the aortic root dimensions requires further careful research.

Sinus of Valsalva aneurysm protruding into the mitral anterior leaflet causing dyspnea: A CARE-compliant case report.

INTRODUCTION: Sinus of Valsalva aneurysm (SVA) protruding into the mitral anterior leaflet is an extremely rare clinical condition; herein, we present a case of unruptured noncoronary SVA protruding into the mitral anterior leaflet. PATIENT'S CONCERNS: A 46-year-old male was referred to hospital for exertional dyspnea. DIAGNOSIS: Transthoracic echocardiography (TTE) and coronary computed tomography angiography (CTA) suggested a noncoronary SVA protruding into the mitral anterior leaflet, causing mitral regurgitation and aortic insufficiency. INTERVENTIONS: The aneurysm was resected and the aortic and mitral valves were replaced with mechanical valves via a transaortic approach. OUTCOMES: Postoperative recovery was uneventful. CONCLUSIONS: A rare noncoronary SVA protruding into the mitral anterior leaflet can be diagnosed via TTE and CTA. Transaortic mitral surgery is feasible in patients with a dilated aortic annulus ring and mitral valve diseases.