Author + information
- Received September 5, 2018
- Accepted October 2, 2018
- Published online January 7, 2019.
- Tatsuya Amano, MD∗ (, )
- Toru Naganuma, MD, PhD and
- Sunao Nakamura, MD, PhD
- ↵∗Address for correspondence
: Dr. Tatsuya Amano, Department of Cardiovascular Medicine, New Tokyo Hospital, 1271 Wanagaya, Matsudo, Chiba, Japan.
The rate of aneurysms in the sinus of Valsalva (SVA) is estimated at 0.09% in the general population according to a large autopsy series (1). Nonruptured SVAs are associated with significant aortic valve regurgitation in 30% to 50% of cases. However, the association of SVAs with aortic stenosis (AS) remains unclear. Although a previous case report has been made regarding the feasibility of transcatheter aortic valve replacement (TAVR) for severe AS with SVAs (2), no reports have investigated the aneurysm status at follow-up. We report on a patient with severe AS who presented with computed tomography (CT)-confirmed SVA stabilization 2 years after undergoing TAVR.
The patient was an 84-year-old woman with symptomatic very severe AS (area, 0.6 cm2; peak/mean gradients, 143/85 mm Hg; ejection fraction, 66%), stable coronary artery disease, hypertension, hyperlipidemia, and post-operative colon cancer.
Although the presence of SVA is not a contraindication for TAVR, it may increase aortic dissection risk. To minimize this risk, the self-expanding Medtronic CoreValve (Medtronic, Tokyo, Japan) was chosen following pre-dilation using a 16-mm Z-MED balloon (NuMed Canada, Inc., Cornwall, Canada). According to CT dimensions a 29-mm CoreValve was chosen and safely deployed under controlled pacing. There were no adverse events during the 2-year follow-up period. Transthoracic echocardiography at 2 years showed an improved effective orifice area of 2.0 cm2, peak/mean gradients of 35/19 mm Hg, and an ejection fraction of 65%. The patient was prescribed aspirin (100 mg) and clopidogrel (75 mg) for 2 years.
Preprocedural CT showed contrast agent flow into the 1.4 × 0.9 cm2 SVA in the right coronary cusp (Figure 1A). One-week later, however, CT could not detect contrast inside the aneurysm (Figure 1B). Furthermore, 6-month and 2-year CT follow-up showed advanced calcification of the aneurysm (Figures 1C and 1D). The size of the aneurysm remained the same during the 2-year period. The CoreValve frame also continued to expand during follow-up.
In a prior study, calcification in the aorta was found to be correlated with decelerated abdominal aneurysm expansion (3). Our results suggest that interruption of blood flow into the SVA because of TAVR led to advanced calcification, which stabilized the SVA.
Dr. Naganuma is a clinical proctor for Medtronic. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose.
- Received September 5, 2018.
- Accepted October 2, 2018.
- 2019 American College of Cardiology Foundation