Case Report: Zero-fluoroscopy retrograde transcatheter closure of a ruptured Sinus of valsalva guided by transesophageal echocardiography.

Background: Ruptured sinus of Valsalva (RSOV) is a rare cardiac lesion that may lead to a progressive right-sided cardiac overload and ultimately heart failure. Although surgery remains the primary intervention, transcatheter closure has emerged as a less invasive alternative in suitable patients. However, zero-fluoroscopy retrograde transcatheter closure of RSOV under echocardiography guidance alone is extremely rare. Case presentation: A 31-year-old man with a history of hypertension presented with symptoms of atypical chest pain and exertional dyspnea. Heart auscultation showed a grade III/VI with a to-and-fro murmur. Pre-procedural transthoracic and transesophageal echocardiography (TTE and TEE) demonstrated a ruptured aneurysm from the right coronary cusp of the sinus of Valsalva with shunting into the right atrium. The defect measured 7 mm at the aortic end and 6 mm at the right atrial end, with a distance of 16.5 mm from the right coronary ostium and no significant aortic regurgitation. The patient underwent a zero-fluoroscopy percutaneous closure using a retrograde transarterial approach under echocardiography guidance only. A Konar-MF VSD Occluder (8/10 mm) was successfully deployed. Post-procedural imaging showed a stable device position, with mild central residual shunt. No obstruction of the right coronary ostium or aortic regurgitation was observed. Final follow-up on TTE examination at 2 years revealed a complete closure without any residual flow. Conclusion: This case demonstrates the technical feasibility of a fully TEE-guided, zero fluoroscopy, retrograde transcatheter closure of RSOV in patients with favorable anatomy. This approach reduces radiation and contrast exposure without altering the short-term procedural success.