Same-Session Percutaneous Closure of Iatrogenic Sinus of Valsalva Rupture During Transseptal Puncture for Balloon Mitral Valvotomy: A Case Report

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  Figure 1. Multimodality imaging demonstrating preprocedural anatomy and detection of sinus of Valsalva (SoV) rupture. (A) Preprocedural transoesophageal echocardiography in the mid-oesophageal long-axis view (132°) demonstrates calcification of the right coronary cusp associated with mild aortic regurgitation. (B) Aortography showing contrast leakage adjacent to the non-coronary cusp, consistent with an iatrogenic rupture of the SoV.

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  Figure 2. Transoesophageal echocardiography (TEE) during the procedure. (A) Standard 2D TEE showing a perforation at the non-coronary cusp (NCC) of the sinus of Valsalva, demonstrated by continuous colour Doppler flow. (B) 3D TEE image illustrating the delivery sheath crossing the NCC at the site of perforation.

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  Figure 3. Final deployment and echocardiographic confirmation of sinus of Valsalva closure. (A,B) Fluoroscopy showing release and final positioning of the multi-fenestrated septal occluder device across the non-coronary cusp rupture site. (C) Short-axis transoesophageal echocardiography confirming stable device position with no residual shunt or significant aortic regurgitation.

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  Figure 4. Final balloon dilation and echocardiographic confirmation post-mitral valvotomy. (A) Fluoroscopy showing Inoue balloon inflation across the mitral valve after multi-fenestrated septal occluder device placement, completing the balloon mitral valvotomy procedure. (B) Transoesophageal echocardiography demonstrates successful commissural splitting of the mitral valve with the device in a stable position. (C) Biplane and 3D colour Doppler confirming preserved transmitral flow.

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  Figure 5. Serial echocardiographic follow-up at 12 months post-procedure. (A) TTE planimetry demonstrating moderate residual mitral stenosis (mitral valve area 1.36 cm2). (B) Transmitral continuous-wave Doppler showing moderate residual mitral stenosis (mean gradient 2.79 mmHg). (C) Parasternal long-axis TTE confirming stable occluder device position (arrow). (D) Parasternal short-axis TTE with colour Doppler demonstrating secure device placement adjacent to the non-coronary cusp without residual shunt or interference with aortic valve cusps (right and left coronary cusps).