Isolated Saccular Pseudoaneurysm of Left Sinus of Valsalva Post Angioplasty: Role of Multimodal Imaging in Diagnosis and Management

INTRODUCTION

Isolated aneurysmal dilation of the left sinus of Valsalva is an uncommon cardiac disease that may have either a congenital or acquired etiology. Right coronary sinus involvement is seen in almost 94% of the cases, and pseudoaneurysms of the non or left sinus are rare (5% and 1%, respectively).^[1] Accurate diagnosis of this rare entity requires intense imaging with the help of various modalities such as transthoracic or transesophageal echocardiography (TEE), coronary computed tomography (CT) angiography, percutaneous cardiac catheterization, and/or cardiac magnetic resonance imaging (MRI). The tendency for sinus of valsalva aneurysm (SOVA) to rupture poses significant risks. Unruptured SVAs being asymptomatic or minimally symptomatic can make early detection difficult, leading to delayed treatment when complications arise. The potential for SVAs to compress the left coronary arteries is another critical concern and this can result in reduced blood flow to the myocardium, causing ischemic symptoms.^[2] Surgical treatment is usually an emergency but may vary according to the features and locations of the pseudoaneurysm. This case report addresses the diagnosis and management of a single saccular pseudoaneurysm of the left sinus of Valsalva in a patient exhibiting persistent angina following angioplasty.

CASE REPORT

A 67-year-old guy arrived at our hospital with chest heaviness and exertional angina (NYHA grade III-IV) persisting for 2 months. The patient reported a medical history of angioplasty and stenting of the left anterior descending artery 2 years before and of the left circumflex coronary artery 1 year earlier for the same symptoms. Transthoracic echocardiography (TTE) revealed an aneurysm of the left coronary sinus measuring 1.7 cm, accompanied by a tricuspid aortic valve, with no evidence of aortic stenosis or regurgitation. The left ventricle measured 4.5 cm in end diastole and 3.1 cm in end systole. The left atrium had modest dilation, measuring 4.3 cm. Akinetic mid-anterior septum and distal interventricular septum were seen, with an ejection fraction recorded at 45%.

Cardiac catheterization revealed a saccular aneurysm of the left coronary sinus measuring 1.6 cm by 1.9 cm [Figure 1]. Calcific lesions were seen in the proximal left anterior descending artery, resulting in 60–70% luminal stenosis. The remaining coronary circulation had adequate flow. A CT aortogram and coronary CT angiography were conducted to confirm the diagnosis, identify any extension or connection of the pseudoaneurysm with neighboring heart chambers, and evaluate the aorta for any pathological conditions. A lobulated contrast-filled outpouching was observed at the ostium of the left main coronary artery (LMCA) originating from the left coronary sinus [Figure 2].

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Figure 1:

Cardiac catheterization showing saccular pseudoaneurysm (blue star) with multiple blockages noted in the left anterior descending artery (purple arrow).

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Figure 2:

Electrocardiogram gated multidetector computed tomography image showing pseudo-aneurysm (green stat) with its close proximity to left coronary ostium (brown arrow).

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The patient was scheduled for urgent treatment of a pseudoaneurysm accompanied by coronary artery bypass grafting surgery. The patient received routine general anesthesia according to hospital practice. The Philips X7-2T TEE probe was utilized for intraoperative monitoring. The mid-esophageal aortic valve short-axis image verified a tri-leaflet aortic valve exhibiting normal leaflet movement and adequate coaptation [Video 1]. An outpouching was observed in the left coronary sinus next to the ostium of the LMCA. The saccular pseudoaneurysm sac was 1.3 cm by 1.6 cm in diameter and 1.6 cm in depth, was lined with organized thrombus, exhibited spontaneous echo contrast, and interacted directly with the aortic root through an aperture of 1.3 cm [Video 2 and Figure 3]. The 3D reconstruction of the picture revealed a clearly delineated aperture of the pseudoaneurysm sac within the aortic sinus [Video 3 and Figure 4].

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Figure 3:

The mid-esophageal aortic valve short-axis view showing the saccular pseudoaneurysm sac measuring 1.3 cm × 1.6 cm in diameter and 1.6 cm in depth and was also noted to be lined with organized thrombus (arrow).

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Figure 4:

The mid-esophageal aortic valve long-axis view showed the pseudoaneurysm sac which was lined with organized thrombi, demonstrated spontaneous echo contrast, and communicated directly with the aortic root through an opening measuring 1.3 cm × 1.6 cm.

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Following median sternotomy and systemic heparinization, off-pump coronary artery bypass grafting was performed utilizing the left internal mammary artery conduit, which was sequentially anastomosed to the diagonal branch and the left anterior descending artery. Root cardioplegia was administered utilizing St. Thomas cardioplegia solution, and the aorta was incised to see the pseudoaneurysm orifice in the sinus [Figure 5]. A pericardial patch of 3 cm × 2 cm was positioned to cover the neck of the sac and surgically closed, ensuring no obstruction of the left major ostium. The duration of extracorporeal circulation during bypass was 75 min, while the aortic cross-clamp duration was 40 min. The post-bypass transesophageal echocardiogram revealed a patch occluding the ostium of the pseudoaneurysm sac, with no evidence of leakage across the patch. No impediment to coronary blood flow was detected with the use of color flow Doppler in the aortic valve short-axis view across the coronary ostium nor were there any regional wall motion abnormalities observed in the transgastric short-axis view.

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Figure 5:

Clinical picture taken after administration of cardioplegia showed the pseudoaneurysm opening (white arrow) in the left coronary sinus near the left main coronary ostium (black arrow).

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Following the surgical procedure, the patient was cared for in the cardiac surgery critical care unit, extubated after 4 h, and released from the intensive care unit on the 3^rd post-operative day with stable hemodynamics.

DISCUSSION

The sinuses of Valsalva are three diminutive chambers situated within the aortic root, next to the aortic valve, facilitating blood flow into the coronary arteries during diastole. The isolated aneurysm of the sinus of Valsalva (SOVA) is uncommon, with an autopsy study indicating a frequency of around 0.09%.^[3] The atypical development of the bulbus cordis during embryogenesis, leading to structural deficiencies in the aorta wall, has been suggested as the primary cause of congenital SOVAs. Association with other congenital anomalies such as ventricular septal defect (30–60%), aortic valve regurgitation (20%), bicuspid aortic valve (10%), and coarctation of the aorta is common.^[2]

Acquired SOVAs may arise owing to the deterioration of the aorta wall over time, observed in ailments such as connective tissue disorders, Marfan syndrome, and Ehlers– Danlos syndrome, as well as infectious diseases including syphilis, infective endocarditis, tuberculosis, trauma, and iatrogenic damage. Isolated pseudoaneurysms of the sinus of Valsalva are typically preceded by a history of catheter-based interventions that resulted in early intimal damage, facilitating the formation of the pseudoaneurysm. Unruptured pseudoaneurysms are typically asymptomatic; however, they may enlarge and exert pressure on neighboring coronary arteries, leading to ischemia, or they may rupture into adjacent cardiac chambers. Additional complications may include valvular regurgitation (aortic, pulmonary, or tricuspid), obstruction of the right ventricle outflow tract, conduction pathway abnormalities, and/or thromboembolic events.^[4,5]

Echocardiography, whether transthoracic or transesophageal, is essential for the early identification of SOVA. A prior research by Cheng et al., determined that surgical intervention could be executed in approximately 95% of instances based exclusively on echocardiographic data obtained from proficient sonographers. The remarkable diagnostic metrics – sensitivity of 93.9%, specificity of 99.9%, and accuracy of 99.8% – exemplify echocardiography’s dependability in detecting SVA and its efficacy in both diagnosis and treatment strategy formulation.^[6] The identification of the distinctive “windsock” dilatation is a crucial echocardiographic finding; however, it may not be attainable in all individuals. Echocardiography of ruptured aneurysms demonstrates a persistent high-velocity jet from the aorta into the cardiac chamber. Multiplane imaging is achievable using the TEE probe, which offers superior echocardiographic views for evaluating the whole aortic root and the proximal ascending aorta. In our situation, TEE allows precise identification of the pseudoaneurysm, including its size and any existing communication.^[7,8] The simultaneous involvement of the corresponding coronary artery ostium in the pseudoaneurysm is essential for assessing the need for concurrent bypass grafting. Meticulous cardiac catheterization can ascertain the anatomical position of the pseudoaneurysm and its association with the coronary ostium, while also revealing any substantial coronary artery disease throughout the artery’s trajectory.

The determination of surgical strategy and planning is predicated on electrocardiogram (ECG)-gated contrast-enhanced multislice coronary CT, which delivers precise data on the location, dimensions, extent, and involvement of adjacent structures. The spatial resolution of cardiac structures observed on contrast-enhanced multi-slice coronary CT far surpasses that of other imaging modalities, offering precise anatomical representation of Valsalva sinus aneurysms and adjacent cardiac structures.^[9] A close proximity of the pseudoaneurysm to the left main coronary ostium was identified on the coronary CT. Moreover, the presence of thrombi in the pseudoaneurysm sac on CT angiography prompted the early surgery to prevent any adverse neurological outcomes.

Intraoperative TEE serves as an essential real-time tool for surgeons, facilitating surgical planning by accurately identifying the location of the pseudoaneurysm, assessing its extent, ruling out the involvement of adjacent structures in the aortic root or rupture into cardiac chambers, and assisting in aortic cannulation. A moderate correlation was seen between measures produced from TTE and TEE (Spearman’s rho [ρ] = 0.609, P < 0.001) as well as between TEE-derived values and those obtained from multi-detector CT (ρ = 0.530, P = 0.001) and cardiac MRI (ρ = 0.667, P = 0.050) in a research conducted by Xu et al. This study ultimately determined that tomographic imaging using multidetector CT and CMR provides extensive diagnostic pre-operative information, whereas TEE is essential for intra-operative guiding.^[10] Intra-operative TEE in a case of sinus of Valsalva pseudoaneurysm is essential for assessing the dimensions of the pseudoaneurysm sac, guiding aortic cannulation, applying the aortic cross clamp, administering cardioplegia, and evaluating the sufficiency of surgical repair post-procedure.

Echocardiography consistently proves its value in spotting small but clinically significant changes, such as early ruptures, abnormal outpouchings, or pressure on nearby vessels. These lessons are directly relevant to an isolated saccular pseudoaneurysm of the left sinus of Valsalva after angioplasty, where subtle injury can easily be missed without attentive imaging. Recognizing these changes early helps protect the coronaries and ensures that the patient receives timely and appropriate care.^[11-14]

As imaging technology continues to progress, multimodal imaging is more essential for the diagnosis, treatment, and surgical planning of complicated aortic sinus pseudoaneurysm procedures. Each imaging modality possesses distinct advantages and constraints, rendering multimodal imaging indispensable for pre-operative surgical planning and decision-making. TTE may typically detect this disease; nevertheless, precise surgical planning needs comprehensive imaging and reconstruction with ECG-gated coronary CT angiography and/or direct cardiac catheterization. Intraoperative TEE serves a unique function in assisting surgeons throughout the procedure, evaluating the sufficiency of surgical repair, and identifying any postoperative problems.

CONCLUSION

Iatrogenic SOV pseudoaneurysm is a rare condition, with a higher prevalence in the right sinus of Valsalva. Diagnosis and treatment need multi-modal imaging. Intraoperative TEE is a crucial instrument during surgery, significantly aiding surgeons in the safe execution of the procedure and assessing the sufficiency of the surgical repair.