Noncoronary Sinus Of Valsalva Research Articles

Changes in aortic root dimensions post aortic root enlargement with Y-incision and modified aortotomy.

Lifetime management in aortic stenosis (AS) can be facilitated by aortic root enlargement (ARE) to improve anatomy for future valve-in-valve (ViV) procedures. A mitral valve-sparing ARE technique ("Y-incision") and sinotubular junction (STJ) enlargement ("roof" patch aortotomy) allow upsizing by 3-4 valve sizes, but quantitative analysis of changes in root anatomy is lacking. Among 78 patients who underwent ARE by Y-incision technique (± roof aortotomy closure) we identified 45 patients with high-quality pre- and post-operative computed tomography angiography (CTA) scans to allow analysis of change in aortic root dimensions. Detailed measurements of the annulus/basilar ring and sinuses were performed by an expert imager on both pre- and post-operative CTAs. The basal ring was defined as the functional annulus when a bioprosthetic valve was present. Average age was 65±11 years, the majority were female (29, 64%), and 9 (20%) had undergone prior aortic valve replacement (AVR). Valve upsizing was ≥3 sizes in 41 (91%). Post-operative mean basal ring diameter was larger compared to the native annular diameter (26.3 vs. 25.3 mm, P<0.01) and substantially larger than prior prosthetic valve in redo AVR (25.6 vs. 19.3 mm, P<0.001). Diameters of the sinuses at pre-operative computed tomography (CT) increased by +7.7±2.8 [right sinuses of Valsalva (R SVS)], +6.7±3.0 [left sinuses of Valsalva (L SVS)], and +6.6±2.9 mm [non-coronary sinuses of Valsalva (N SVS)]. Mean diameter of the STJ increased to 38.3±3.7 post-operative (+8.1±3.2 mm). Left main (LM) and right coronary artery (RCA) heights decreased by -6.3±3.3 and -3.7±3.4 mm respectively due to the supra-annular position of the valve, however, the post-operative valve-to-coronary (VTC) artery distances were 6.6±2.3 and 4.9±2.0 mm, respectively. The Y-incision root enlargement technique significantly enlarges the sinus and STJ diameters by 6-7 mm while preserving VTC distances despite upsizing by 3-4 valve sizes, resulting in post-operative anatomy that is favorable for future transcatheter aortic valve-in-surgical aortic valve (TAV-in-SAV).

Completion Bentall procedure for a huge aortic root pseudoaneurysm after surgery for acute aortic dissection: A case report

A 56-year-old man with a history of emergency ascending aortic and aortic valve replacement for acute type A aortic dissection 6 months previously developed a huge pseudoaneurysm arising from the sinus of Valsalva due to recurrent aortic root dissection. The patient urgently underwent the completion Bentall procedure with coronary artery reconstruction using interposing grafts. During surgery, the non-coronary sinus of Valsalva was repeatedly dissected and ruptured, where surgical glue was applied in the previous operation. The 25-mm REGENT mechanical valve&amp;reg; from the previous operation was left in place, and 2-0 bladed mattress sutures were circumferentially placed in the sewing ring of the prosthesis. A 28-mm Valsalva graft&amp;reg; was cut at the middle of its skirt portion, through which these sutures were passed and tied, and was seated to completely cover the valve cuff. The completion Bentall procedure is considered a feasible technique for reoperative aortic root replacement in patients with a prosthetic aortic valve following acute type A aortic dissection repair. It is important to accurately measure the outer diameter of the prosthetic valve to ensure proper fit of the graft and to minimize the risk of bleeding.

Multi-modality imaging diagnosing 'wandering non-coronary Valsalva sinus aneurysm'.

Multi-modality imaging diagnosing 'wandering non-coronary Valsalva sinus aneurysm'.

Potential Clinical Usefulness of Post-Valvular Contrast Densities to Determine the Severity of Aortic Valve Stenosis Using Computed Tomography.

Different methods are established for the changes in aortic valve stenosis with cardiac computed tomography angiography (CCTA), but the effect of the grade of stenosis on contrast densities around the valve has not been investigated. Using the information from flow dynamics in cases of increased velocity through narrowed lumen, the hypothesis was formed that flow changes can alter the contrast densities in stenotic post-valvular regions, and the density changes might correlate with the grade of stenosis. Forty patients with severe aortic stenosis and fifteen with a normal aortic valve were enrolled. With echocardiography, the peak/mean transvalvular gradients, peak transvalvular velocity, and aortic valve opening area were obtained. With CCTA, densities 4-5 mm above the aortic valve; at the junction of the left, right, and noncoronary cusp to the annulus; at the middle level of the left, right, and noncoronary sinuses of Valsalva in the center and the lateral points; at the sinotubular junction; and 4 cm from the sinotubular junction at the midline were measured. First, a comparison of the densities between the normal and stenotic valve was performed, and then possible correlations between echocardiography and CCTA values were investigated in the stenotic group. In all CCTA regions, significantly lower-density values were detected among stenotic valve patients compared to the normal aortic valve population. Additionally, in both groups, higher densities were measured in the peri-jet regions than in the lateral ones. Furthermore, a good correlation was found between the aortic valve opening area and the densities in almost all perivalvular areas. With regard to the densities at the junction of the non-coronary leaflet to the fibrotic annulus and at the most lateral point of the right sinus of Valsalva, a high level of correlation was found between all echocardiography and CCTA parameters. Lastly, with receiver operating characteristic curve measurements, area under the curve values were between 0.857 and 0.930. Certain CCTA density values, especially 4-5mm above the valve opening, can serve as auxiliary information to echocardiography when the severity of aortic valve stenosis is unclear.

“UFO procedure” for massive aortic and mitral annular calcification involving left atrial and ventricular myocardium: a potential radical solution

BackgroundThe “UFO procedure” was initially developed as a surgical option to enlarge the aortic annulus in patients requiring valve replacement. This technique can be employed to treat extensive endocarditis located in the intervalvular fibrous body (IVFB). One of the indications for a "UFO procedure" is massive aortic and mitral valve calcification. It is a challenging surgical procedure with a high risk of intraoperative complications.Case summaryWe present a 76-year-old male patient with massive aortic and mitral valve calcification involving the left atrium, the left ventricle and the left ventricular outflow tract. Both valves exhibited severe stenosis and moderate to severe regurgitation. The left ventricle was hypertrophic and the left ventricular ejection fraction was > 55%. The patient was prediagnosed with persistent atrial fibrillation. The risk of death following heart surgery (EuroSCORE II) was calculated as 9.21%. We successfully performed a so-called “UFO procedure” including replacement of both valves without annular decalcification to avoid atrioventricular dehiscence. We enlarged the IVFB and replaced the non-coronary sinus of Valsalva with doubled bovine pericardium. The left ventricular outflow tract was decalcified. The patient was transferred to a local hospital on the 13th postoperative day.ConclusionSuccessful surgical treatment to this extent was demonstrated for the first time. Due to the high perioperative mortality, the surgical treatment of patients with this constellation would be refused in most cases. In our patient, the preoperative imaging showed extreme calcification of both valves and the surrounding myocardium. Excellent preoperative planning and a highly experienced surgical team is necessary.

DO NOT RUSH TO BLAME THE ARTERIAL LINE. BEFORE TAKING IT OUT, SCAN THE AORTA

<h3>Objective</h3> Cardiac Anaesthesiologists has the unique advantage of assessing the cardiovascular system through various methods. Non-invasive and invasive hemodynamic monitoring accompanied by Transoesophageal Echocardiography (TOE) with 3D imaging, create an integrated profile of pressure, volume, flow velocity and anatomical information for every patient. In the current case report, we highlight the role of TOE and 3D imaging in diagnosing a previously unknown Coarctation of the Aorta (CoA), and thus interpreting correctly the arterial waveform of a femoral arterial line that was initially considered to be malfunctioning. <h3>Design and Method</h3> A 53yr old male patient was scheduled for Aortic Valve plus partial Aortic Root plus Ascending Aorta replacement. The background included a bicuspid aortic valve (Sievers Type 0: no raphe) with moderate mixed valvular disease, aortic root aneurysm with unequal dilatation of the sinuses of Valsalva, and an ascending aorta aneurysm. Intraoperatively, a right brachial cuff for Non-Invasive Blood Pressure (NIBP) was placed before the anesthesia induction, whilst after that an arterial line was introduced in the left femoral artery (Figure 1). Because of the fact that the arterial waveform had a damped shape, a delayed upslope and a 30mmHg difference with the NIBP, after having ruled out any connection issues, a second arterial line was inserted into the left radial artery. The second waveform had a normal shape and was numerically matching the NIBP, having therefore the same pressure difference with the femoral line (Figure 2,3). Keeping in mind the patient's background, the suspicion of CoA was raised. <h3>Results and Conclusion</h3> The comprehensive TOE examination that followed, including 3D imaging, confirmed the already known patient's background, but more importantly proved the existence of CoA, showed its precise anatomy and appreciated quite accurately the previously noticed pressure difference between the two arterial waveforms (Figure 4,5,6,7,8). Due to the fact that the summary of the preoperative CT angiography was not describing any pathology in the descending aorta, a further analysis of the CT with 3D reconstruction was requested at that moment; the clinical suspicion and the echocardiographic findings were verified (Figure 9,10). As fas as the surgical procedure is concerned, the patient underwent a mechanical aortic valve replacement, replacement of the non-coronary sinus of Valsalva and of the ascending aorta with an interposition graft. No intervention regarding the CoA was performed. In conclusion, in this case report we showed that a damped arterial waveform - a clinical finding that could have been overlooked and the arterial line to be consequently removed - constituted the first step towards a definite diagnosis. Undoubtedly, crucial in the diagnostic process proved to be the role of TOE, and more specifically a comprehensive and not only focused to the main pathology TOE examination. However, it is the clinical suspicion that should be always kept high.

Atrioventricular Ring Tachycardias: Atypical Fast-Slow Atrioventricular Nodal Reentrant Tachycardia and Atrial Tachycardia Share a Common Arrhythmogenic Substrate-A Unifying Proposal.

Our understanding of the variants of slow pathway (SP) and associated atypical atrioventricular (AV) nodal reentrant tachycardia (NRT) is still growing. We have identified variants extending outside Koch's triangle along the tricuspid annulus, including superior, superoanterior and inferolateral right atrial SP and associated atypical, fast-slow AVNRT. We review the history of each variant, their electrophysiological characteristics and related atypical AVNRT, and their treatment by catheter ablation. We focused our efforts on organizing the published information, as well as some unpublished, reliable data, and show the pitfalls of electrophysiological observations, along with keys to the diagnosis of atypical AVNRT. The superior-type of fast-slow AVNRT mimics adenosine-sensitive atrial tachycardia originating near the AV node and can be successfully treated by ablation of a superior SP form the right side of the perihisian region or from the non-coronary sinus of Valsalva. Fast-slow AVNRT using a superoanterior or inferolateral right atrial SP also mimics atrial tachycardia originating from the tricuspid annulus. We summarize the similarities among these variants of SP, and the origin of the atrial tachycardias, including their anatomical distributions and electrophysiological and pharmacological characteristics. Moreover, based on recent basic research reporting the presence of node-like AV ring tissue encircling the annuli in adult hearts, we propose the term "AV ring tachycardia" to designate the tachycardias that share the AV ring tissue as a common arrhythmogenic substrate. This review should help the readers recognize rare types of SP variants and associated AVNRT, and diagnose and cure these complex tachycardias. We hope, with this proposal of a unified tachycardia designation, to open a new chapter in clinical electrophysiology.

A Fatal Case of an Undiagnosed Ruptured Aneurysm of the Noncoronary Sinus of Valsalva.

A Fatal Case of an Undiagnosed Ruptured Aneurysm of the Noncoronary Sinus of Valsalva.

Transcatheter closure of a rare ruptured giant non-coronary Valsalva sinus aneurysm.

Transcatheter closure of a rare ruptured giant non-coronary Valsalva sinus aneurysm.

Contained rupture of a sinus of Valsalva aneurysm: Is it just a matter of luck?

BackgroundContained rupture of the ascending aorta is a rare condition, but the severity of this complication enforces strict guidelines for its prevention and a prompt diagnosis, once already occurred.Case presentationA 66-year-old man with a history of type 2 diabetes, longstanding aortic valve stenosis and aortic root aneurysm of 47 mm was hospital admitted for elective surgery. A Bentall-De Bono procedure was performed in order to replace the stenotic bicuspid aortic valve and exclude the dilated portion of the aortic wall. Intraoperatively, a discontinuity of the aortic wall, just above the aortic annulus, at the non-coronary sinus of Valsalva was incidentally observed. The aortic wall discontinuity was none other than a contained aortic rupture. The preoperative CT-scan images were afterwards analyzed by the radiologist, in order to identify the contained aortic rupture. Indeed a false aneurysm of the non-coronary sinus of Valsalva of a maximum diameter of 15 mm was detected, thanks to a 3D reconstruction.ConclusionsThe diagnosis of contained aortic rupture is certainly demanding, particularly in absence of signs or symptoms of rupture in a chamber of the heart or in the pericardium. Although this case represents a consensus of experts’ opinion, the recognition of these specific cases in which the risk of dissection, rupture or death is at its highest, would allow to operate at the appropriate time, improving the outcomes.

Surgical Repair of Unruptured Pseudoaneurysm of Sinus of Valsalva in Aortic Stenosis

Isolated pseudoaneurysm of a sinus of Valsalva is an uncommon sequelae of infective endocarditis. It is very uncommon in native aortic valve stenosis as compared to aortic regurgitation. We present a case of a 46 year old gentleman with a severely stenotic aortic valve with infective endocarditis, and a pseudoaneurysm of the non coronary sinus of Valsalva. The pseudoaneurysm was repaired with a prosthetic patch and the aortic valve was replaced by a mechanical prosthesis. Transthoracic echocardiography and computed tomography aortogram are an ideal diagnostic tools in suspected cases. Surgery can be curative with excellent results.

Prevalence and ablation of different anatomic locations of atrial tachicardias in the electrophysiology lab of a single large center

Abstract Funding Acknowledgements Type of funding sources: None. Introduction Focal atrial tachycardias (ATs) can arise from several different anatomic regions both in the right atrium (RA) and left atrium (LA). The prevalence of focal atrial tachycardia is not well known. A European study of young males applying for pilot licenses demonstrated that 0.34% had asymptomatic atrial tachycardia and 0.46% had symptomatic atrial tachycardia1. It is well-recognized that these foci do not occur randomly throughout the atria but tend to cluster at characteristic anatomic locations. However, the distribution of these sites in the total amount of ATs is not well recognized. Purpose The objective of this study was to determine the prevalence of different anatomic locations of ATs in the electrophysiology lab of a single large center (300 ablations per year) and to verify the site of ablation. Methods We collected 150 consecutive patients submitted to catheter ablation of ATs between January 2010 to December 2020. Anatomic localization of the atrial focus was performed during tachicardia by analysis of endocardial activation sequence. Results The distribution of the different anatomic locations is rappresented in the figure. In 134 patients (89%) ATs were localized in the RA. In the RA, these foci mainly occured along the crista terminalis (32%), the perinodal region (22,6%), the anterior right sided septum, near the foramen ovale (9,3%), the posterior right-sided septum (8%), the ostium of the coronary sinus (5,3%), the tricuspid annulus (5,3%), the superior vena cava (4,6%), the infero-lateral wall (2,5%), the right atrial appendage (0,6%) and the cavotricuspid histhmus (0,6%). In the LA (11%), foci occur predominantly at the pulmonary vein ostia (5,2%) and less commonly at the mitral annulus (2,5%), the left sided septum (0,6%), the appendage ridge (0,6%), the roof (0,6%) and the anterior wall (0,6%). For each location of AT, the ablation was performed at the earliest activation site, but about the perinodal ATs, the ablation was performed at the non coronary sinus of Valsalva of the aortic root, regardless the earliest activation site, for avoiding to create damages to the atrio-ventricular (AV) conduction system. Conclusions ATs mainly arise from the RA. Crista terminalis is the most common site but the perinodal region is the second more frequent site. The ablation of ATs from the perinodal region is challenging for the risk of damages to the AV conduction system. The relatively low prevalence of ATs arising from the pulmonary veins could be explained for the likely degeneration of these ATs in atrial fibrillation. Abstract Figure.

A Giant Ruptured Noncoronary Sinus of Valsalva Aneurysm: A Case Report

The occurrence of a giant ruptured aneurysm originating from the noncoronary sinus of Valsalva in the right atrium is extremely rare. Herein, a case is presented of a giant ruptured noncoronary sinus of Valsalva aneurysm (SVA) that was protruding into the right atrium, which was almost completely occupied by an aneurysm. A 61-year-old female was referred to the hospital for exertional palpitation and dyspnea. While a surgical repair was performed by resection of the aneurysm and a sinus remodeling with a patch of fresh bovine pericardium, a very rare case was observed. It was a giant ruptured noncoronary sinus of aneurysm that completely occupied the right atrium, which was difficult to distinguish from the coronary aneurysm. It is also believed that various imaging examinations, such as cardiac computed tomography angiogram (CCTA) and transthoracic echocardiogram (TTE), were useful for the diagnosis.

Rupture of Sinus of Valsalva Mimicking Aortic Root Dissection: Surgical Management and Factors Influencing Immediate Survival

Rupture of giant aneurysm of sinus of Valsalva usually requires surgery to prevent life-threatening complications from occurring. We report the case of a 55-year-old patient with a previous history of aortic valve replacement who was urgently referred to our institution with a superior vena cava syndrome and dyspnea. CT-scan initially misdiagnosed a dissection of the aortic root that was ultimately a contained rupture of a giant aneurysm of the non-coronary sinus of Valsalva. Despite a sudden hemodynamic deterioration with a collapse and cardiac arrest, urgent salvage surgery was successfully performed with an uneventful outcome. Physiopathogeny of hemodynamic profiles influencing immediate survival and surgical technique are discussed in this report.

Catheter ablation of atrial tachycardia from the non-caronary valsalva sinus

A case report of atrial tachycardia ablation form the non-coronary Valsalva sinus is presented.

Wrapping Tape Operation during Correction of Aortic Stenosis (15 Years of Clinical Experience)

&#x0D; The aim. To study the clinical possibilities of the original technique of the wrapping tape operation (WTO) of the dilated post-stenotic ascending aorta (AA) during surgical correction of aortic stenosis (AS).&#x0D; Materials and methods. The study group included 196 patients who were operated on for the prevailing AS combined with poststenotic dilation of the ascending aorta (PDAA) for the period from 01.01.2006 until 01.01.2020 at the National Amosov Institute of cardiovascular surgery of the National Academy of Medical Sciences of Ukraine. All the patients underwent aortic valve replacement (AVR) combined with the original technique of WTO. During echocardiographic examination, the diameter of the AA before surgery was 47.7±1.7 mm, and the diameter of the Valsalva sinuses was 37.4±1.8 mm. The original technique of the correction of PDAA included plication of the non-coronary Valsalva sinus, as the most vulnerable zone, reduction of the AA diameter, creation of its reliable framework in order to prevent further AA dilation in the long term.&#x0D; Results. Hospital mortality was 0.5%. In the long term, the outcomes in 185 patients (94.4% of the number of discharged patients) were studied. The follow-up period was 8.1±0.8 years. In the long-term period, 8 (4.1%) patients died. The AA diameter at the time of discharge was 39.1±1.5 mm and 40.3±1.1 mm in the long term, and the diameter of the Valsalva sinuses was 34.5±1.5 mm and 34.8±1.3 mm, respectively. Complications or deaths associated with the technique of the intervention on the aortic root and AA were not observed both at the hospital stage and in the long term. None of the patients was reoperated due to further AA dilation.&#x0D; Conclusions. The proposed technique has established itself as a fairly reliable, safe procedure. In addition, it is costeffective since it does not require the use of a vascular prosthesis. The technique is useful for the correction of AS and PDAA from 4.0 to 5.2 cm.

Catheter ablation of atrial tachycardia via extracardiac access

A female patient with nonautomatic focal atrial tachycardia with paraHissian location of the focus and previously unsuccessful ablation attempt in the right atrium (RA) is presented. Electroanatomic mapping demonstrated sequential activation of the anteroseptal area of the RA, anteroseptal area of the left atrium and non-coronary sinus of Valsalva with minimal differences in local activation times. Because of perceived risk of conduction disturbances ablation was done in the non-coronary sinus with immediate termination of the tachycardia, subsequent non-inducibility and without any complications.

CATHETER ABLATION OF ATRIAL TACHYCARDIA FROM THE NON-CARONARY VALSALVA SINUS

A case report of atrial tachycardia ablation via non-coronary Valsalva sinus is presented.

Florida sleeve technique for a right sinus of Valsalva aneurysm: a case report

BackgroundFlorida sleeve technique was reported by Hess et al. as a new technique of valve sparing aortic root replacement without the requirement of entire aortic root wall resection and coronary artery reconstruction. We present a rare case of an unruptured aneurysm of the right sinus of Valsalva that was successfully treated with resection of the aneurysm and the Florida sleeve technique.Case presentationA 72-year-old man was admitted for the treatment of an unruptured aneurysm of the right sinus of Valsalva. Computed tomography showed an aneurysm of the right sinus of Valsalva measuring > 40 mm and protruding into the right ventricular outflow tract. The aneurysm dilated up to 5 mm per year, and the left sinus of Valsalva and non-coronary sinus of Valsalva also showed dilation, and he underwent resection of only the right sinus of Valsalva aneurysm and valve sparing aortic root replacement with the Florida sleeve technique.ConclusionsWe performed valve-sparing aortic root replacement with the Florida sleeve technique. It could reduce surgical risks and prevent a dilatation of the residual sinus of Valsalva through coverage with a graft for a long term.

VD05 BENTALL OPERATION IN BICUSPID VALVE AND ANOMALOUS LEFT CIRCUMFLEX CORONARY ARTERY: ANATOMICAL AND TECHNICAL IMPLICATIONS

Abstract Bicuspid aortic valve (BAV) is often associated with coronary abnormalities. The finding of BAV associated with an anomalous circumflex coronary artery (ACCA) originating from the right Valsalva sinus (VS) and surrounding the non-coronary VS is however a rather rare occurrence. We report a case of successful Bentall operation with a composite button technique in a 56-year-old man with aortic root dilatation, BAV insufficiency and coexisting ACCA. In this case a 25 SJM composite graft was implanted in supraannular fashion rather than intraannular to avoid: 1) ACCA injury or obstruction of the proximal course near the annulus by suture ligation, 2) compression by prosthetic ring, 3) distortion of ACCA during ostia reimplantation. We demonstrated that attention to the anatomic relationship of ACCA to the aorta is crucial and prosthesis supraannular implantation technique allows a safe aortic root replacement.