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Table of Contents
Year : 2018  |  Volume : 3  |  Issue : 1  |  Page : 38-40

A rare complication: The rupture of sinus of valsalva during the percutaneous coronary intervention

Department of Cardiology, Shanxi Provincial People's Hospital, Shanxi, China

Date of Web Publication16-May-2018

Correspondence Address:
Shunming Zhu
Department of Cardiology, Shanxi Provincial People's Hospital, Shaanxi 710068
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/cp.cp_8_18

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Rupture of the sinus of Valsalva is an extremely rare complication of percutaneous coronary intervention. It could lead to lethal sequelae if not coded properly. We experienced a rupture of sinus of Valsalva during the percutaneous coronary intervention which led to pericardial tamponade, causing hemodynamic instability. Surgery was performed immediately, and the patient was discharged without symptoms. Manipulation of the guiding catheter should be performed with great caution during the whole procedure, especially in patients with hypertension, atherosclerosis, or other diseases.

Keywords: Complication, percutaneous coronary intervention, rupture, sinus of Valsalva

How to cite this article:
Zhu H, Du J, Gao Y, Cui Q, Xing Y, Zhu S. A rare complication: The rupture of sinus of valsalva during the percutaneous coronary intervention. Cardiol Plus 2018;3:38-40

How to cite this URL:
Zhu H, Du J, Gao Y, Cui Q, Xing Y, Zhu S. A rare complication: The rupture of sinus of valsalva during the percutaneous coronary intervention. Cardiol Plus [serial online] 2018 [cited 2019 Aug 20];3:38-40. Available from: http://www.cardiologyplus.org/text.asp?2018/3/1/38/232553

  Introduction Top

Nowadays, percutaneous coronary intervention is performed commonly all over the world. Yet, fatal complications happen occasionally, which would lead to grave consequences. Here, we report an extremely rare complication, rupture of the sinus of Valsalva.

  Case Report Top

A 73-year-old male patient was admitted with unstable angina with a minor history of stroke 3 years prior without sequel. He denied a history of hypertension, diabetes, Marfan's syndrome, or connective tissue disorder. The patient felt aggravation of angina even after thorough conservative treatment. The 12-lead electrocardiogram was normal, and cardiac enzymes were not elevated upon admission. The physical examination was unremarkable. He was taken for cardiac catheterization. Selected coronary angiography manifested total occlusion in the proximal segment of the right coronary artery (RCA); 80%–90% stenosis existed in the 11–13 segment of left circumflex artery (LCX); and 95% stenosis existed in the 6 segment of the left anterior descending artery (LAD). After discussing the options of percutaneous coronary intervention (PCI) or coronary artery bypass graft, PCI was performed first for occlusion of the RCA.

A guiding wire was inserted into the distal of the RCA. 20 mm × 20 mm Sapphire balloon was inflated at pressure of 12 atm. A 2.5 mm × 36 mm Lepu stent (Lepu, Beijing, China) was deployed at the occlusion at a pressure of 12 atm. The procedure was smooth and successful. The stenosis of LAD and LCX was planned to intervene a week later. The patient was stable in the coming week. In the second angiography procedure, the previous stent was in good state, and the results were identical to the previous angiogram. The patient experienced chest pain when the EBU guiding catheter was sending to the bottom of aortic sinus. The blood pressure dropped quickly from 110/70 mmHg to 90/60 mmHg, and the heart rate increased from 80 bpm to 110 bpm. An angiogram showed contrast medium diffusing into the pericardial cavity [Figure 1]. Paracentesis pericardii was immediately performed. The blood pressure dropped to 80/50 mmHg even after high-dose dopamine infusion. The diffusion was enhancing continuously [Figure 2] and [Figure 3]. Autologous blood transfusion and allogeneic transfusion were implied at the same time, but the blood pressure remained unstable. Pericardial tamponade worsened in minutes. Under the X-ray, the shade of the heart was enormously enlarged [Figure 4]. Surgery was performed immediately.
Figure 1: Angiogram showed contrast medium diffusing into pericardial cavity

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Figure 2: The diffusion was enhancing

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Figure 3: The diffusion was enhancing continuously

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Figure 4: The shade of the heart was enormously enlarged

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During the surgery, a rupture of the noncoronary sinus of Valsalva (approximately 5 cm) was visualized. The rupture was closed with a 5/0 Prolene artificial patch. Great saphenous vein grafts were used to connect the ascending aorta to the proximal LCX and LAD as bridge connections. The surgery was accomplished after 6 h. The operative procedure included repair of rupture of sinus of Valsalva and coronary artery bypass graft under general anesthesia and cardiopulmonary bypass. Echocardiography was applied twice after surgery with no pericardial effusion noted. The patient recovered and was discharged without symptoms 20 days after the surgery.

  Discussion Top

Rupture of sinus of Valsalva rarely happened during the interventional procedure. There are no articles reporting the rate of sinus of Valsalva rupture, although Dunning reported during PCI, iatrogenic aortic dissection occurs in 0.02%–0.07% of cases.[1] In our laboratory, the rate was 0.03% (1 in 34,512 who underwent angiography). It was fatal once the complication occurred. The attributions of aortic complication were mostly catheter trauma and balloon inflation.[2]

The iatrogenic trauma of aorta(including sinus of Valsalva), would lead to occlusion of the coronary artery and the dissection of the ascending aorta and further. Also, the trauma would rupture the aortic wall causing the massive haemorrhage lethally.[3],[4] In our case, the rupture tore the vessel wall, and blood diffused into the cavum pericardii, causing hemodynamic instability.

The mechanisms of iatrogenic trauma of sinus of Valsalva during angiography might be vigorous contrast medium injection, subintimal passage of the guiding catheter, and inappropriate handling of the guiding catheter. Once the entry ports of the vessel wall were started, the shearing forces of blood flow could promote the extension of the dissection or rupture. The process in hypertensive patients, or patients with degenerative medial diseases, such as cystic medial necrosis or atherosclerotic change, would apt to promote. Hypertension, atherosclerosis, dyslipidemia, and other disease could cause necrosis of smooth muscle cells and fibrosis of elastic structures of the vessel wall. Such pathological mechanisms enhance the vulnerability to iatrogenic trauma of the vessel wall.[5]

Due to its rarity, there are no guidelines for rupture of sinus of Valsalva during interventional procedure. In our case, surgery was the only available option due to the instability of hemodynamic and residual coronary stenosis.[6] In conclusion, rupture of sinus of Valsalva is a lethal complication during interventional procedure. Guiding catheter manipulation, contrast injections, or balloon inflation should be performed carefully during the procedure.

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


Conflicts of interest

There are no conflicts of interest.

  References Top

Dunning DW, Kahn JK, Hawkins ET, O'Neill WW. Iatrogenic coronary artery dissections extending into and involving the aortic root. Catheter Cardiovasc Interv 2000;51:387-93.  Back to cited text no. 1
Shah P, Bajaj S, Shamoon F. Aortic dissection caused by percutaneous coronary intervention: 2 New case reports and detailed analysis of 86 previous cases. Tex Heart Inst J 2016;43:52-60.  Back to cited text no. 2
Yip HK, Wu CJ, Yeh KH, Hang CL, Fang CY, Hsieh KY, et al. Unusual complication of retrograde dissection to the coronary sinus of valsalva during percutaneous revascularization: A single-center experience and literature review. Chest 2001;119:493-501.  Back to cited text no. 3
Shin SY, Joo HJ, Lim SY, Park SM, Hong SJ, Shim WJ, et al. Delayed rupture of the right sinus of valsalva into the right atrium after percutaneous coronary intervention. Korean J Intern Med 2009;24:388-92.  Back to cited text no. 4
Nabati M, Bagheri B, Eslami S, Piran R. Spontaneous aortic dissection limited to the sinus of valsalva: Report of two cases. J Tehran Heart Cent 2016;11:34-7.  Back to cited text no. 5
Núñez-Gil IJ, Bautista D, Cerrato E, Salinas P, Varbella F, Omedè P, et al. Incidence, management, and immediate- and long-term outcomes after iatrogenic aortic dissection during diagnostic or interventional coronary procedures. Circulation 2015;131:2114-9.  Back to cited text no. 6


  [Figure 1], [Figure 2], [Figure 3], [Figure 4]


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