Transcatheter closure of ruptured sinus of Valsalva aneurysm using the Amplatzer duct occluder: immediate results and mid-term follow-up

To assess the immediate and mid-term outcome of transcatheter closure (TCC) using the first-generation Amplatzer duct occluder (ADO) in patients with ruptured sinus of Valsalva aneurysm (SOVA). Ruptured SOVA is a rare cardiac shunt lesion, with scant data about its TCC. Twenty patients (8 females and 12 males) aged 17–52 years (median 27 years) with ruptured SOVA were selected for TCC. Most (13/20) were in symptomatic NYHA class III or IV. Three had previous cardiac surgeries. Associated defects were bicuspid aortic valve in one, trivial pre-existing aortic regurgitation (AR) in five, coarctation of the aorta in one, and secundum atrial septal defect in one. Patients with co-existing ventricular septal defect or significant AR requiring surgery were excluded. Echocardiography revealed ruptured SOVA from right coronary sinus to right atrium (RA) in 4 and right ventricular (RV) outflow in 5, whereas non-coronary sinus ruptured into RA in 10 and RV inflow in 1. At cardiac catheterization, the defect was 4–11 mm (median 9 mm) at its aortic end as measured by online transoesophageal echocardiography or angiography. The Qp/Qs ratio ranged from 1.5 to 3.2 (mean 2.32 ± 0.53). In all patients, the defect was closed from the venous side, using ADOs 2–4 mm larger than the aortic end of the defect. The ADO sizes ranged from 8/6 to 16/14 mm (median 13/11 mm). The procedure was successful in 18 out of 20 patients (90%). Of these 18, 13 had a complete closure at discharge. Five had a residual shunt (four small and one moderate with self-abating haemolysis). Trivial AR occurred in four. On a median follow-up of 24 months (range 1–60 months), 15 patients were in NYHA class I and 3 in class II. The residual shunt disappeared in three and was small in two; procedure-related AR vanished in two of four. There was no AR progression, recurrence, infective endocarditis, or device embolization. In appropriately selected patients with ruptured SOVA, TCC is an attractive alternative to surgery with encouraging short- and mid-term outcomes.