Ann Thorac Surg 1998;65:535
© 1998 The Society of Thoracic Surgeons
Case Reports
Aneurysm of the Left Sinus of Valsalva Producing Aortic Valve Regurgitation and Myocardial Ischemia
Yoshiharu Takahara, MD,
Yoshio Sudo, MD,
Tooru Sunazawa, MD,
Nobuyuki Nakajima, MD
Division of Cardiovascular Surgery, Funabashi Municipal Medical Center, Funabashi, Japan
Accepted for publication September 10, 1997.
Dr Takahara, 1-21-1, Kanasugi, Funabashi, Chiba 273, Japan.
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Abstract
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An aneurysm of the left sinus of Valsalva producing aortic valve regurgitation was treated by excising the aortic root including the aneurysm but leaving the aortic valve leaflets. The aortic valve was reimplanted inside a graft. Postoperative examinations revealed normal aortic valve function. In this case, the cause of aortic valve regurgitation was due to deformity of the aortic annulus. An aortic valve-sparing operation is an appropriate method for such a case.
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Introduction
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An isolated aneurysm of the left sinus of Valsalva is a rare cardiac abnormality, and a patient in this particular situation usually suffers from aortic valve regurgitation. The surgical treatment usually consists of resection or plication of the aneurysm and replacement of the aortic valve [1] [2] [3] [4]. We report a case successfully treated by an aortic valve-sparing operation.
A 66-year-old man was admitted to our hospital because of an abnormal mediastinal shadow on chest x-ray examination. On physical examination, blood pressure was 100/50 mm Hg and the pulse rate was 70 beats/min with regular sinus rhythm. There was a grade 2/6 diastolic regurgitant murmur at the left sternal border. Cardiac index obtained by thermodilution was 2.2 L · min-1 · m-2. Left ventricular ejection fraction was 0.34. An aortic root angiogram showed a large aneurysm arising from the left coronary sinus, a stretched and narrowed left main coronary artery, and grade 3/4 aortic valve regurgitation (Fig 1). There was no dilatation of the aortic annulus. Radioisotope examination showed diffuse left ventricular ischemia. We suspected that left main coronary artery compression might have been the cause of the cardiac dysfunction.
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An aortic root angiogram digital subtraction angiogram showed a large aneurysm arising from the left coronary sinus and a grade 3/4 aortic valve regurgitation.
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An operation was performed through a median sternotomy with mild hypothermic cardiopulmonary bypass. Fig 2 demonstrates the pathology and the surgical management that was employed. The ascending aorta was transected just beyond the aneurysmal dilatation. The aneurysm orifice was 2 cm in diameter at the left sinus of Valsalva. The aneurysm, which was 10 cm in diameter, was located distal to this orifice. The aortic valve leaflets were configured normally and showed no sign of pathology. The left main coronary artery was stretched, but there was no palpable disease of the coronary vessels.
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The aortic annulus is deformed by compression of the aneurysm. There is a stretched and narrow left main coronary artery. (b) The left main coronary artery has no stenotic lesion. All sinuses are excised, leaving 5 mm of aortic wall attached to the aortic valve. (c) The aortic valve is reimplanted into the graft. The coronary arteries are also reimplanted.
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The proximal ascending aorta was dissected circumferentially down to the level of the aortic valve. All three sinuses of Valsalva were excised, leaving 5 mm of aortic wall attached to the aortic valve as well as to the commissures. The left and right coronary ostia were dissected with a 3-mm button of surrounding aortic wall. Thirteen horizontal mattress sutures were passed from the inside to the outside of the left ventricular outflow tract. These sutures placed through the existing tissue just under the valve orifice. The aortic valve leaflet height was 16 mm. A collagen-impregnated tubular Dacron graft (26 mm in diameter) was chosen for the procedure. The previously placed horizontal mattress sutures were passed through the near end of the proximal stump of the graft. The aortic valve was placed inside of the graft, and all the sutures were tied outside of the graft. The remnants of the aoric wall attached to the aortic valve were additionally sutured to the graft wall. Both coronary ostia were reimplanted into the graft. The distal end of the graft was then anastomosed to the ascending aorta.
The patient was weaned from cardiopulmonary bypass uneventfully. A postoperative angiogram showed trivial aortic valve regurgitation but normal left ventricular contraction.
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Comment
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An isolated aneurysm of the left sinus of Valsalva with aortic valve regurgitation has been treated by resection or plication of the aneurysm with aortic valve replacement [1] [2] [3] [4]. Recently an aortic valve-sparing operation has been described as an effective procedure for the management of annuloaortic ectasia [5]. We therefore assumed that an aortic valve-sparing operation could be applied to an isolated aneurysm of the left sinus of Valsalva. In annuloaortic ectasia, enlargement of the annulus causes aortic valve regurgitation, whereas in this case the aortic regurgitation was the result of the deformity of the annulus at the left sinus, secondary to compression by the aneurysm. We successfully repaired the defect by resecting the aneurysm, and we were able to preserve the aortic valve by correcting the deformity of the annulus by inserting an artificial graft. We believe the preservation of the aortic valve to be the procedure of choice in such a patient without aortic valve cusp abnormalities.
An isolated aneurysm of the left sinus of Valsalva may be associated with myocardial infarction or ischemia due to obstruction or stenosis of the left main coronary artery [1] [3] [4]. Before operation, our patient showed compromised cardiac function, which was caused by stenosis of the left main coronary artery due to aneurysmal compression. Cardiac function improved after elimination of left main coronary arterial compression. A coronary artery bypass graft should be considered in those patients with occlusion or stenosis of the left main coronary artery that can not be corrected by repair of the aneurysm alone.
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References
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- Garcia-Rinaldi R, Koch LV, Howell JF Aneurysm of the sinus of Valsalva producing obstruction of the left main coronary artery. J Thorac Cardiovasc Surg 1976;72:123-126.[Abstract]
- Williams TG, Chir M, Williams BT Isolated unruptured aneurysm of the left coronary sinus of Valsalva. Ann Thorac Surg 1983;35:556-559.[Medline]
- Hiyamuta K, Ohtsuki T, Shimamatsu M, et al. Aneurysm of the left aortic sinus causing acute myocardial infarction. Circulation 1983;67:1151-1154.[Abstract/Free Full Text]
- Brandt J, Jögi P, Lührs C Sinus of Valsalva aneurysms obstructing coronary arterial flow: case report and collective review of the literature. Eur Heart J 1985;6:1069-1073.[Abstract/Free Full Text]
- David TE, Feindel CM An aortic valve-sparing operation for patients with aortic incompetence and aneurysm of the ascending aorta. J Thorac Cardiovasc Surg 1992;103:617-622.[Abstract]
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Abstract
Introduction
