Congenital aneurysm of the left coronary sinus and left main coronary artery with fistulous communication to the right atrium in pregnancy

Rupture of a non sinus of Valsalva aneurysm during pregnancy: Case report and review of literatures

Ruptured Sinus of Valsalva aneurysms during pregnancy is rare and presents a threat both to the mother and the fetus. We report a case of ruptured nonsinus of Valsalva aneurysms in a 26-year-old woman diagnosed at 32⁺⁴ weeks of gestation. A successful elective lower-segment cesarean section was conducted under general anesthesia. A successful surgical correction of the ruptured aneurysm under cardiopulmonary bypass (CPB) was performed with patch repair after 13 days. A multidisciplinary approach with respect to the pregnant patient's diagnosis, indications, and timing of surgery is necessary in ensuring the best possible outcomes for both the mother and the child.

Paediatric-onset coronary artery anomalies in pregnancy: a single-centre experience and systematic literature review

OBJECTIVES

Individuals with childhood-onset coronary artery anomalies are at increased risk of lifelong complications. Although pregnancy is thought to confer additional risk, a few data are available regarding outcomes in this group of women. We sought to define outcomes of pregnancy in this unique population.

METHODS

We performed a retrospective survey of women with paediatric-onset coronary anomalies and pregnancy in our institution, combined with a systematic review of published cases. We defined paediatric-onset coronary artery anomalies as congenital coronary anomalies and inflammatory arteriopathies of childhood that cause coronary aneurysms. Major cardiovascular events were defined as pulmonary oedema, sustained arrhythmia requiring treatment, stroke, myocardial infarction, cardiac arrest, or death.

RESULTS

A total of 25 surveys were mailed, and 20 were returned (80% response rate). We included 46 articles from the literature, which described cardiovascular outcomes in 82 women (138 pregnancies). These data were amalgamated for a total of 102 women and 194 pregnancies; 59% of women were known to have paediatric-onset coronary artery anomalies before pregnancy. In 23%, the anomaly was unmasked during or shortly after pregnancy. The remainder, 18%, was diagnosed later in life. Major cardiovascular events occurred in 14 women (14%) and included heart failure (n=5, 5%), myocardial infarction (n=7, 7%), maternal death (n=2, 2%), cardiac arrest secondary to ventricular fibrillation (n=1, 1%), and stroke (n=1, 1%). The majority of maternal events (13/14, 93%) occurred in women with no previous diagnosis of coronary disease.

CONCLUSIONS

Women with paediatric-onset coronary artery anomalies have a 14% risk of adverse cardiovascular events in pregnancy, indicating the need for careful assessment and close follow-up. Prospective, multicentre studies are required to better define risk and predictors of complications during pregnancy.

Anesthetic management of cesarean delivery in parturients with ruptured sinus of Valsalva aneurysm: CARE-compliant 2 case reports and literature review

RATIONALE

Ruptured sinus of Valsalva aneurysm is rare and dangerous in parturients. Few cases of ruptured SVA in pregnancy are reported, and the anesthetic management for cesarean delivery has scarcely been described.

PATIENT CONCERNS

A parturient at 37-week gestation complained of a sore throat and cough that started 3 days before admission, followed 1 day later by fever, dizziness, breathlessness, and palpitation on exertion. Case two at 36-week gestation complained of a 1-day history of bloating in the lower abdomen.

DIAGNOSES

Full term and preterm parturients with ruptured sinus of Valsalva aneurysm.

INTERVENTIONS

Cesarean deliveries were performed with incremental epidural anesthesia technique under invasive monitoring. Surgical correction of the ruptured sinus of Valsalva aneurysms and ventricular septal defect were performed uneventfully 13 days and 7 days postpartum, respectively, for the 2 cases.

OUTCOMES

No complications were observed in the intra- or postoperative period for both mothers and babies.

LESSONS

We reviewed the pertinent literature and reached the following conclusions: use of a multidisciplinary team to guide anesthetic management is helpful and necessary; and both general anesthesia and incremental epidural anesthesia can be safely used in parturients with ruptured sinus of Valsalva aneurysm.

Left circumflex to right atrial coronary arterio-venous fistula - role of multimodality imaging for diagnosis

We report an interesting case presenting with progressive dyspnea and palpitations. The patient underwent multimodal imaging procedures consisting of two dimensional echocardiography, MRI, cardiac catheterization and also a three dimensional transesophageal echocardiographic reconstruction. All the investigations taken together helped us in finally arriving at accurate anatomical diagnosis of a coronary AV fistula from the left circumflex artery to the right atrium. The patient finally underwent a successful non-surgical closure using an Amplatzer device. The role of three-dimensional echocardiographic evaluation in defining the anatomy for planning the treatment is emphasized.

Ruptured sinus of Valsalva aneurysm from left coronary sinus into right atrium: a rare anomaly with an odd presentation

We report a case of a 42-year-old man presenting with shortness of breath and palpitation on exertion, who was evaluated to have left sinus of Valsalva aneurysm rupturing into right atrium. This is a very rare congenital cardiac anomaly with variable clinical presentation ranging from asymptomatic detection on imaging to acute coronary syndrome and sudden cardiac death. Rupture is the most dreaded complication and usually manifests as an acute event. Aneurysmal dilation less commonly affects the left sinus and rupture into the right atrium is still rarer and a chronic insidious presentation as in this case is odd.

Outcome of cardiovascular surgery and pregnancy: a systematic review of the period 1984-1996

The outcomes of cardiovascular operations during pregnancy, at delivery, and post partum were reviewed from published material in the period 1984-1996. Surgery during pregnancy resulted in fetal-neonatal morbidity and mortality of 9% and 30%, respectively, and in maternal morbidity and mortality of 24% and 6%, respectively. Duration of pregnancy at surgery and duration and temperature of cardiopulmonary bypass did not influence fetal-neonatal outcome. Maternal complications and mortality of surgery immediately after delivery were 29% and 12%, respectively, and for surgery performed with a postpartum interval the respective rates were 38% and 14%. Hospitalization after week 27 of gestation and extreme emergency contributed significantly to poor maternal outcome. Maternal deaths were reported in 9% of valvular procedures and in 22% of aortic or arterial dissection repairs and pulmonary embolectomies. Fetal-neonatal risks of maternal surgery during pregnancy are high and unpredictable. Maternal risks of cardiovascular procedures during pregnancy are moderate, significantly increase if an operation is performed at or after delivery, and, overall, should be considered as higher than those in nonpregnant cardiovascular surgical patients.

Intracardiac shunts

Unsuspected intracardiac shunts can be a cause of acute deterioration in critically ill patients. Shunts can be acquired or congenital conditions that become symptomatic only with changed physiologic conditions. Transesophageal echocardiography is an excellent tool for the diagnosis of intracardiac shunts.

Aortoatrial fistulae diagnosed by transthoracic and transesophageal echocardiography: advantages of the transesophageal approach

Aortoatrial fistulae are uncommon, providing a difficult diagnostic challenge both in the clinical diagnosis and in the choice of an imaging modality that fully delineates the abnormal anatomy and flow patterns. This report describes four cases of aortoatrial fistula resulting from three different underlying causes. The fistula communicated with the right atrium in three cases and the left atrium in one. We also describe the diagnostic information obtained during both transthoracic and transesophageal echocardiography and stress that full detail of the abnormal anatomy and shunting could be obtained only with the transesophageal approach, with its improved image quality of the aortic root. No extra information, other than the coronary anatomy, was obtained during aortography in the two patients who underwent cardiac catheterization. Transesophageal echocardiography should, therefore, be the investigation of choice in patients in whom there is a suspicion of aortoatrial shunting after clinical examination and routine transthoracic studies, and it may avoid the need for invasive investigation in these potentially hemodynamically unstable patients.

Intrapartum care of a woman with aortic aneurysms

Advances in technology and complex care have enabled women with various health problems to become and remain pregnant. Consequently, health-care practitioners are seeing an increasing number of pregnant women who have aortic aneurysms. This case study describes the culturally sensitive intrapartum care of a Middle Eastern woman with ascending and descending aortic aneurysms.