Anesth Analg 2006;102:369-371
© 2006 International Anesthesia Research Society
doi: 10.1213/01.ane.0000189255.30188.cc
CARDIOVASCULAR ANESTHESIA
Sinus of Valsalva Aneurysm and Ventricular Tachycardia During Pulmonary Artery Catheterization
Chirag Patel, MD, and
Peter L. Bailey, MD
Department of Anesthesiology, University of Rochester, Rochester, New York
Address correspondence and reprint requests to Peter Bailey, MD, Department of Anesthesiology, Box 604, 601 Elmwood Ave., Rochester NY, 14642. Address e-mail to peter_bailey{at}urmc.rochester.edu.
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Abstract
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Pulmonary artery catheterization is associated with numerous complications, including serious arrhythmias. We report a case where ventricular tachycardia occurred repeatedly during attempted pulmonary artery catheterization, precluding successful catheterization. Transesophageal echocardiography was used to image the tricuspid valve and right ventricle and revealed a Sinus of Valsalva aneurysm protruding significantly into the right ventricle and obstructing advancement of the pulmonary artery catheter. Our case reveals another identifiable cause of serious arrhythmia during pulmonary artery catheterization and highlights how transesophageal echocardiography can be useful in unanticipated ways during cardiac anesthesia and surgery.
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Introduction
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Pulmonary artery catheterization is associated with numerous complications, including serious arrhythmias such as heart block and ventricular tachycardia. We report a case where ventricular tachycardia occurred repeatedly during attempted pulmonary artery catheterization. The rare, and previously unreported, cause of the problem became apparent when transesophageal echocardiography (TEE) was used to image the tricuspid valve and right ventricle and serve as a guide in the placement of the pulmonary artery catheter.
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Case Report
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The patient was a 62-yr-old male with a history of atypical chest pain. Preoperative echocardiographic examination revealed a Sinus of Valsalva aneurysm. Angiographic study revealed his aortic root to be enlarged. Surgery was planned for correction of the Sinus of Valsalva aneurysm and the enlarged aortic root. After IV induction of anesthesia with 1 µg/kg of sufentanil, 250 mg of sodium thiopental, and 80 mg of rocuronium, a tracheal tube and TEE probe were placed. Anesthesia was maintained with an IV sufentanil infusion (1 µg · kg–1 · h–1) and 1% inspired concentration of isoflurane with a fresh gas flow of air and oxygen, 1 L/min each. Catheterization of the right internal jugular vein was ultrasound-assisted and easily performed, and pulmonary artery catheterization was attempted. On advancing the pulmonary artery catheter out of the right atrium and into the right ventricle, and immediately upon obtaining a right ventricular pressure tracing, ventricular tachycardia was noted on the electrocardiogram. The ventricular tachycardia persisted for a few seconds but ceased upon withdrawal of the pulmonary artery catheter back into the right atrium. Systemic blood pressure was normal before and immediately after the arrhythmia but the patient was hypotensive (70/35 mm Hg) during the ventricular tachycardia. Ventricular tachycardia recurred immediately during two more attempts to advance the pulmonary artery catheter and the arrhythmia abated abruptly again on withdrawal of the catheter. It was decided to use TEE to image the tricuspid valve and right ventricle to assist pulmonary artery catheterization. Midesophageal views of the tricuspid valve and right ventricle (Figs. 1 and 2) revealed that the Sinus of Valsalva aneurysm was protruding significantly into the right ventricle and that the aneurysm was preventing advancement of the pulmonary artery catheter through the right ventricle and into the pulmonary artery. This most likely forced the pulmonary artery catheter into the right ventricular free wall, causing the arrhythmia. Further attempts to advance the pulmonary artery catheter were delayed until after cardiopulmonary bypass.
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Figure 1. A midesophageal image of the tricuspid valve and right ventricle obtained at zero degrees using a multi-plane imaging probe that revealed a mass (white arrow) in the right ventricle that was preventing advancement of the pulmonary artery catheter. RA = right atrium; RV = right ventricle.
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Figure 2. A midesophageal image of the tricuspid valve and right ventricle obtained at 84 degrees (RV inflow/outflow view) using a multi-plane imaging probe that revealed the large Sinus of Valsalva aneurysm (white arrow) protruding into the right ventricle. RA = right atrium; TV = tricuspid valve; SVA = Sinus of Valsalva Aneurysm; RVOT = right ventricular outflow tract.
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After aortic root replacement and termination of cardiopulmonary bypass, the pulmonary artery catheter was advanced into proper position without difficulty. The remainder of the patient’s hospital stay was uneventful.
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Discussion
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Sinus of Valsalva aneurysm is an uncommon cardiac defect with an incidence of 0.14%–0.23% (1). It is reportedly more common in Asian individuals, and it is more common in males than females. It can be either a congenital or acquired defect. Congenital forms usually involve only one sinus. They are often caused by an abnormal aortic media that results in a separation or discontinuity of the media from the aortic annulus fibrosis (1). Deficiency of normal elastic tissue and abnormal development of the bulbus cordis have also been proposed as a pathologic mechanism (1). The right Sinus of Valsalva is more commonly involved in congenital aneurysms (67%–85%) than are the noncoronary sinus (10%) and left coronary sinus (<5%). Associated anomalies most commonly include a ventricular septal defect (30%–60%), aortic insufficiency (20%–30%), or a bicuspid aortic valve (10%) (1). Acquired Sinus of Valsalva aneurysms most often are caused by endocarditis, cystic medial necrosis, atherosclerosis, or trauma, and, compared with congenital aneurysms, they more frequently involve more than one sinus.
Patients with an aneurysm of the Sinus of Valsalva that has not ruptured are often asymptomatic. The natural history of such aneurysms is unclear. Patients without a ruptured sinus aneurysm may, however, present with a variety of symptoms including fatigue, palpitations, dyspnea on exertion, near syncope, angina, dysphagia, and chest pain (2). Symptoms are likely a result of obstruction and/or compression of surrounding structures such as the conduction system and the coronary arteries. Aneurysm rupture, most often into the right atrium or ventricle, can occur. Although the consequences of rupture can be mild, acute hemodynamic decompensation and death can result (2). Acute cardiac tamponade can develop with aneurysm rupture. Resultant fistulae can cause congestive heart failure. The associated mortality is frequent if the condition is not rapidly recognized and treated (3). Transthoracic echocardiography can be used to diagnose the condition but TEE can be useful, as it was in our case, to better characterize the anatomy and pathophysiology (2). Surgical intervention is the definitive therapy, although less invasive approaches have been reported as well (4).
Because patients with an aneurysm of the Sinus of Valsalva may be asymptomatic, our case reveals yet another unusual, but identifiable, cause of serious arrhythmia during attempted pulmonary artery catheterization. Our case also highlights, as so many already reported cases have, how TEE can be useful in unanticipated ways during cardiac anesthesia and surgery. Although rare, Sinus of Valsalva aneurysm is another mechanism whereby pulmonary artery catheterization may prove to be difficult and potentially hazardous.
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Footnotes
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Supported by the Department of Anesthesiology, University of Rochester, Rochester, New York.
Accepted for publication September 9, 2005.
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References
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- Ring WS. Congenital Heart Surgery Nomenclature and Database Project: aortic aneurysm, Sinus of Valsalva aneurysm, and aortic dissection. Ann Thoracic Surg 2000;69:S147–63.[Abstract/Free Full Text]
- Blackshear JL, Safford RE, Lane GE, et al. Unruptured noncoronary Sinus of Valsalva aneurysm: preoperative characterization by transesophageal echocardiography. J Am Soc Echocardiogr 1991;4:485–90.[Medline]
- Mayer ED, Ruffmann K, Saggau W, et al. Ruptured aneurysms of the Sinus of Valsalva. Ann Thoracic Surg 1986;42:81–5.[Abstract]
- Jean WH, Kang TJ, Liu CM, et al. Transcatheter occlusion of ruptured Sinus of Valsalva aneurysm. J Formosa Med Assoc 2004;103:948–51.[Medline]
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Abstract
Introduction
