Unusual cause of tricuspid valve obstruction after surgical aortic valve replacement

Sreekanth Yerram1, Tella Ramakrishna Dev2, Srinivas Bhyravavajhala1
1 Department of Cardiology, Nizam's Institute of Medical Sciences, Hyderabad, Telangana, India
2 Department of Cardiothoracic Surgery, Nizam's Institute of Medical Sciences, Hyderabad, Telangana, India

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Date of Submission24-Jul-2021Date of Decision05-Sep-2021Date of Acceptance19-Feb-2022Date of Web Publication16-Nov-2022

Abstract

Unruptured sinus of Valsalva aneurysm can present with manifestations due to local compression or protrusion into the chambers. Right ventricular inflow obstruction is a rare manifestation. This image highlights the tricuspid valve obstruction due to a Valsalva aneurysm in a patient after surgical aortic valve replacement.

Keywords: Aortic valve replacement, right ventricular inflow obstruction, tricuspid stenosis, unruptured sinus of Valsalva aneurysm

How to cite this article:
Yerram S, Dev TR, Bhyravavajhala S. Unusual cause of tricuspid valve obstruction after surgical aortic valve replacement. Ann Pediatr Card 2022;15:317-9
How to cite this URL:
Yerram S, Dev TR, Bhyravavajhala S. Unusual cause of tricuspid valve obstruction after surgical aortic valve replacement. Ann Pediatr Card [serial online] 2022 [cited 2022 Nov 23];15:317-9. Available from: https://www.annalspc.com/text.asp?2022/15/3/317/361232

Case

A 52-year-old female with severe aortic regurgitation, moderate aortic stenosis, and a bicuspid aortic valve underwent surgical valve replacement with a bileaflet metallic prosthesis 4 years back. There was mild dilation of the ascending aorta, and there was no abnormality in the sinuses at the time of surgery. Hence, the ascending aorta was not intervened during the aortic valve replacement. After 6 months of the procedure, she presented with giddiness and an episode of presyncope precipitated by exertion. Clinical examination was normal except for a minimally raised jugular venous pressure. Echocardiography demonstrated a large unruptured sinus of Valsalva aneurysm (SOVA) arising from the noncoronary aortic sinus, protruding into the right ventricular (RV) inflow, causing turbulence [[Figure 1], [Figure 2] and Videos 1 [Additional file 1], Video 2 [Additional file 2]]. The mean gradient across the tricuspid valve was elevated at 9 mmHg [Figure 3]. Computed tomography scan confirmed the aneurysmal dilation of the noncoronary sinus (3.4 cm × 2.8 cm × 2.4 cm) indenting the tricuspid valve [Figure 4] and [Figure 5]. There was no evidence of rupture, and the prosthetic valve was functioning normally. The SOVA might be a consequence of iatrogenic injury to the media during surgery which is one of the rare causes of SOVA and has been reported after aortic valve surgery.[1] SOVA causing right ventricular outflow tract obstruction is well known, unlike tricuspid stenosis. A few cases of RV inflow obstruction due to SOVA have been reported.[2],[3] However, no similar case could be found in which a SOVA caused RV inflow obstruction after aortic valve replacement. The patient has been advised surgery but chose to be on follow-up.

Figure 1: Echocardiography in the right ventricular inflow view with color comparison showing the bulging noncoronary sinus into the inflow of the RV causing turbulence. SOVA – Sinus of Valsalva aneurysm, RV - Right ventricular

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Figure 2: Parasternal short-axis view demonstrating the unruptured sinus of Valsalva aneurysm

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Figure 4: Double oblique axial thin-section MIP image on CT showing the aneurysmal dilation of noncoronary sinus of Valsalva (arrow)

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Figure 5: Oblique coronal thin-section maximum-intensity-projection image obtained at electrocardiographic-gated computed tomography at showing the replaced aortic valve and the aneurysmal dilation of noncoronary sinus of Valsalva

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Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

References

1.Weinreich M, Yu PJ, Trost B. Sinus of valsalva aneurysms: Review of the literature and an update on management. Clin Cardiol 2015;38:185-9.

2.Gunay R, Sensoz Y, Kayacioglu I. Giant unruptured non-coronary sinus of Valsalva aneurysm presenting as tricuspid stenosis. Eur J Cardiothorac Surg 2010;37:1471.

3.Bagga S, Mohite PN, Reddy S, Thingnam SK, Talwar KK. Unusual cause of rapidly progressive right-sided heart failure: Aortic sinus of Valsalva aneurysm causing ball valve obstruction of the tricuspid valve. Eur J Echocardiogr 2009;10:721-3.