A thirty four-year-old Asian man was admitted to our department with chest pain and palpitation for 3 days. His past medical history was unremarkable. There was no history of syncope. Clinical examination revealed tachycardia, short breath, high volume pulse with blood pressure of 110/55 mmHg. Auscultation revealed a louder and longer continuous diastolic murmur at the left third intercostal edge. Moist rale were heard in the bilateral lung fields. Echocardiography showed that RSVA was present in the right coronary cusp. The sinus opened into the right atrium, and the diameter of the opening was 5 mm. There was no aortic regurgitation.
We addressed all treatment ways to the patient. To the patience preoperative, including the procedure and complications. This patience worried about cardiopulmonary bypass and the trauma by whole thoracotomy. And also he did not want to undertake the risking of reoperation as the closure failing with percutaneous intervention. After informed consent, patient agreed for the transthoracic closure.
The surgery was performed under general anesthesia with endotracheal intubation. Intraoperative transesophageal echocardiography (TEE) was performed to monitor the procedure. The maximal diameter of the opening of the RSVA was measured by TEE (Figure 1). The distance between the aortic opening site of the RSVA and the right or left coronary ostium was also measured. Sternum upper segment “J form” incision was made to expose the heart. After the pericardium was opened, heparin (1 mg/kg) was administered. Draw a straight line from the opening to the right coronary sinus. The intersection point between the line and ascending aorta was chosen for the puncture point. A guide wire with a soft and floppy end was placed into the right atrium through the rupture opening. Then, an 6-Fr delivery sheath (shape memory alloy material CO, LTD, shanghai, China) was sent into the right atrium along the guide wire. A VSD occluder (shape memory alloy material co., LTD, shanghai, China) 2 mm larger than the maximal diameter of the RSVA opening was implanted along the sheath. The first disc was opened in the right atrium and was pulled back to anchor at the rupture site, then another disc was opened. When the left to right shunt disappeared, the rest of the device was deployed (Figure 2). The whole procedure was guided and monitored by TEE. Aortic valve regurgitation or residual shunt was exclude before detaching the device. After detaching the device from the delivery cable, TEE was repeated to evaluate the position of the occluder, residual shunt and aortic valve function. The patient received aspirin (100 mg per day) for a six months period and follow-up. Transthoracic echocardiography was examined at intervals of 1, 3 and 6 months after discharge. The result was satisfactory. There was no significant complications.