Accurate localization of ruptured sinus of Valsalva aneurysm by real-time two-dimensional Doppler flow imaging

Acquired aortocameral fistula occurring late after infective endocarditis: An emblematic case and review of 38 reported cases

AIM

To delineate the features and current therapeutic option of congenital and acquired aortocameral fistulas (ACF) secondary to iatrogenic or infectious disorders.

METHODS

From a PubMed search using the term "aortocameral fistula", 30 suitable papers for the current review were retrieved. Reviews, case series and case reports published in English were considered. Abstracts and reports from scientific meetings were not included. A total of 38 reviewed subjects were collected and analyzed. In addition, another case - an adult male who presented with ACF between commissures of the right and non-coronary sinuses and right atrium as a late complication of Staphylococcus aureus infective endocarditis of the AV - is added, the world literature is briefly reviewed.

RESULTS

A total of thirty-eight subjects producing 39 fistulas were reviewed, analyzed and stratified into either congenital (47%) or acquired (53%) according to their etiology. Of all subjects, 11% were asymptomatic and 89% were symptomatic with dyspnea (21 ×) as the most common presentation. Diagnosis was established by a multidiagnostic approach in 23 (60%), single method in 14 (37%) (echocardiography in 12 and catheterization in 2), and at autopsy in 2 (3%) of the subjects. Treatment options included percutaneous transcatheter closure in 12 (30%) with the deployment of the Amplatzer duct or septal occluder and Gianturco coil and surgical correction in 24 (63%).

CONCLUSION

Acquired ACF is an infrequent entity which may occur late after an episode of endocarditis of the native AV. The management of ACF is generally by surgical correction but non-surgical device intervention has recently been introduced as a safe alternative.

Echocardiographic features of an unruptured mycotic aneurysm of the right aortic sinus of Valsalva

This report describes a 25-year-old man with a pierced tongue in whom Streptococcus constellatus endocarditis of the aortic valve developed. Bacterial endocarditis in this patient was complicated by the development of a mycotic aneurysm of the right aortic sinus of Valsalva. Transthoracic and transesophageal echocardiographic studies were useful for the diagnosis of this rare lesion. Findings were confirmed at operation.

Congenital sinus of Valsalva aneurysm: a multiplane transesophageal echocardiographic experience

Sinus of Valsalva aneurysm is a rare congenital anomaly which, if overlooked, may be associated with increased mortality and morbidity. Multiplane transesophageal echocardiography proved useful in identifying a variety of associated structural heart disease. This study sought to assess the accuracy of the surgical result on the basis of the multiplane transesophageal echocardiography findings and to describe patient demographics and clinical outcome in an Oriental patient cohort. From July 1984 to December 1995, clinical, catheterization, echocardiographic, and surgical results were retrospectively studied in 23 patients with documented sinus of Valsalva aneurysm. Compared with previous reports of Oriental patients, our patient cohort was older (p < 0.025), had more associated aortic, mitral, and tricuspid regurgitation (p < 0.01), but had fewer coexistent ventricular septal defects (p < 0.01), and had more associated coronary artery disease (9%). Multiplane transesophageal echocardiography precisely showed three undiagnosed and/or ambiguous transthoracic echocardiographic studies, and the preoperative transesophageal echocardiography TEE findings were confirmed intraoperatively in the last eight consecutive patients. We concluded that multiplane transesophageal echocardiography provides conclusive information and is the current technique of choice for diagnosis and clinical management of patients with sinus of Valsalva aneurysm; although the natural history of sinus of Valsalva aneurysm remains uncertain, it is likely that the incidence of unruptured sinus of Valsalva aneurysm is considerably higher in the elderly than has been previously reported.

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.

Doppler echocardiographic characteristics of sinus of valsalva aneurysms

This study evaluated the efficacy of a comprehensive transthoracic Doppler echocardiographic examination for correct detection of SVA and its associated lesions of VSD and aortic insufficiency. A consecutive series of 36 patients was obtained; all had surgical confirmation of the anatomic defects. The location of the SVA was correctly determined in 97% of patients, and the associated presence of a VSD was correctly determined in 79% of the studies. In the cases in which Doppler was available, all 11 patients with associated aortic insufficiency were detected. In this series 32 patients had right SVA, 3 had noncoronary sinus SVA, and 1 had a left SVA. Relative frequency of the rupture site location corresponded closely to that in previous necropsy studies. It is concluded that transthoracic Doppler echocardiography can correctly localize SVAs and most associated lesions.

Ruptured Sinus of Valsalva Detected by Biplane Transesophageal Echocardiography

This case illustrates the importance of biplane transesophageal echocardiography and color flow Doppler imaging in detecting a sinus of Valsalva aneurysm and fistula. It also demonstrates how endocarditis can be a complication of this condition.

Right aortic sinus of Valsalva-to-right ventricle fistula complicating bacterial endocarditis of membranous ventricular septal defect: evaluation by two-dimensional, color flow, and Doppler echocardiography

Rupture of the aortic sinus of Valsalva into the right ventricle is a rare complication of bacterial endocarditis. The majority of previous cases have been reported in patients with aortic valve endocarditis. This report describes this complication in association with infective endocarditis of a congenital membranous ventricular septal defect. Color flow imaging showed a mosaic-colored continuous flow signal from the right aortic sinus to the right ventricle. Continuous wave Doppler interrogation showed high-velocity systolic and diastolic flow signals due to continuous left-to-right shunt from the aorta to the right ventricle. The left-to-right shunt through a restrictive membranous ventricle septal defect was visualized as a mosaic-colored high-velocity systolic flow signal. These echocardiographic-Doppler findings permitted surgical correction of these defects without cardiac catheterization.

Sinus of Valsalva aneurysms

Sinus of Valsalva aneurysms are rare cardiac anomalies which may be acquired or congenital. The congenital aneurysm is more common than the acquired form, with an incidence ranging from 0.1 to 3.5% of all congenital heart defects. Acquired aneurysms may result from trauma, endocarditis, syphilis, Marfan's syndrome, and senile-type dilatation in which the three sinuses dilate as a result of the normal aging process. This review focuses on both congenital and acquired aneurysms with particular attention to the noninvasive diagnosis of this anomaly.

Diagnosis of ruptured sinus of Valsalva aneurysms: potential value of transesophageal echocardiography

Two patient cases are reported in which an aneurysm of the right coronary sinus of Valsalva ruptured into the right ventricular outflow tract, near the crux of the heart. Transthoracic two-dimensional echocardiography and transesophageal echocardiography using Doppler color flow mapping allowed accurate preoperative assessment of the left-to-right shunt, which was subsequently confirmed by contrast aortography and surgery.