Clinical Images

“Donut Sign” for Unknown Sinus of Valsalva Mass on Echocardiography: Overhanging Stent

Sunil N. Gurmukhani, DM1; Pradyot Tiwari, DM1; Munish Dev, DM1; Nishith Saradava, MD2; Nikita Chaturvedi, MD2; Shradha Runwal, MD2; Preeti Gahlan, MD2; Sanjay Shah, DM1; Tejas M. Patel, DM1   

Sunil N. Gurmukhani, DM1; Pradyot Tiwari, DM1; Munish Dev, DM1; Nishith Saradava, MD2; Nikita Chaturvedi, MD2; Shradha Runwal, MD2; Preeti Gahlan, MD2; Sanjay Shah, DM1; Tejas M. Patel, DM1   

J INVASIVE CARDIOL 2020;32(8):E220. 

Key words: angiography, cardiac imaging, echocardiography


A hypertensive, diabetic man in his 60s with previous history of multivessel stenting presented with class 3 angina despite optimum medical therapy. On transthoracic echocardiography, there was an unusual, non-mobile, echodense, railroad-track like structure measuring 13 x 4 mm in the right coronary cusp (Figures 1A and 1B; Videos 1 and 2) in long-axis view. It appeared to be a circular, donut-like structure (“donut sign”) in the right coronary cusp (Figure 1C; Video 3) in short-axis view. The echocardiographic features of this mysterious structure were not compatible with any tumor, calcium, or vegetation. As the patient had history of coronary intervention in the past, we suspected overhanging stent from the right coronary artery (RCA). Selective coronary angiogram confirmed overprotrusion of his RCA stent into the aorta (Figure 1D; Video 4). This stent overprotrusion barred us from selective engagement of RCA.

The clinical significance of overprotrusion of coronary stent into the aorta is still not well defined in the literature. Potential problems may include nidus for thrombus and subsequent embolization, as well as complications in subsequent interventions, such as difficulty engaging the ostium and stent distortion by guide catheter and/or balloon.

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From the 1Apex Heart Institute, Gujarat, India; and 2Smt. N.H.L. Municipal Medical College, Ahmedabad, India.

Disclosure: The authors have completed and returned the ICMJE Form for Disclosure of Potential Conflicts of Interest. The authors report no conflicts of interest regarding the content herein.

The authors report that patient consent was provided for publication of the images used herein.

Manuscript accepted December 3, 2019.

Address for correspondence: Sunil Nichaldas Gurmukhani, DM, Apex Heart Institute, Mondeal Business Park, SG Highway, Ahmedabad, PIN 380059, Gujarat, India. Email: drsunilgurmukhani@gmail.com

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