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Fulltext A challenging case report of acute sinus of Valsalva aneurysm rupture in cardiogenic shock and multi-organ failure with an emphasis on rapid recognition and 'never giving up' in face of futility

Jin QW, Jeswant Dillon J, Tjen Jhung L, Isman Rusani B

Eur Heart J Case Rep, 2020 Dec;4(6):1-5.
PMID: 33442636 DOI: 10.1093/ehjcr/ytaa441

Background : Sinus of Valsalva aneurysm (SoVA) is a rare anomaly and can be divided into acquired and congenital forms, the latter being commonly associated with ventricular septal defects (VSDs). Rupture is a catastrophic complication with high mortality without urgent surgical intervention. We would like to highlight the use of echocardiography in an emergency setting for diagnosis and surgical intervention in a critically ill patient.
Case summary : We report a 27-year-old female with history of conservatively managed VSD known since childhood. She presented with acute decompensated cardiac failure requiring intubation and inotropic support. Bedside echocardiography performed in the emergency department suggested a ruptured SoVA at the right coronary cusp with underlying supracristal VSD. Despite the patient being critically ill with multi-organ failure, surgery was performed as it was the patient's best chance for survival. Intraoperative findings tallied with the early echocardiographic results. She recovered gradually and was eventually discharged despite a stormy post-operative period.
Discussion : This case report highlights the importance of prompt recognition of SoVA rupture by using bedside echocardiography. Surgical intervention needs to be early despite ongoing sepsis in view of acute mechanical failure. This case was unique as it illustrates a successful management of an acutely ill patient with multi-organ failure through early diagnosis, intensive perioperative stabilization, and surgical intervention.
Novel treatment of atrial functional tricuspid regurgitation using transcatheter bicaval valve implantation (TricValve)

Jin QW, Mohd Ghazi AB, Kolanthaivelu J, Azmi Yahaya S

AsiaIntervention, 2022 Oct;8(2):138-142.
PMID: 36483273 DOI: 10.4244/AIJ-D-21-00037

BACKGROUND: Transcatheter tricuspid valve intervention has recently emerged as a viable alternative to surgery for patients with symptomatic severe tricuspid regurgitation (TR). Though usually performed on the basis of compassionate grounds, we are now exploring the extension of its usage as an elective option in a patient with severe atrial functional tricuspid regurgitation.
AIMS: The aim of this study was to select a suitable patient and proceed with the implantation of the TricValve in order to provide symptomatic relief as well as to improve morbidity and mortality.
METHODS: A 67-year-old woman had underlying atrial fibrillation and severe tricuspid regurgitation. Despite optimised medical therapy, she remained symptomatic with elevated NT-proBNP levels. As the patient refused surgery on multiple occasions, we chose a percutaneous procedure guided by transoesophageal echocardiography and fluoroscopy.
RESULTS: The procedure was uneventful and the patient was discharged. At 3-month follow-up, there was marked improvement clinically and biochemically.
CONCLUSIONS: Bicaval valve implantation with the TricValve is a viable alternative to surgery in patients with symptomatic severe tricuspid regurgitation. This intervention is crucial as we are now able to intervene before irreversible right ventricular dysfunction sets in.

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