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Ann Thorac Surg 2000;70:1470-1471
© 2000 The Society of Thoracic Surgeons

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Discussion

Discussion

Discussion

DR W. STEVES RING (Dallas, TX): I would like to thank the Society for the opportunity to discuss this paper and I would like to thank Dr Azakie and his colleagues from Toronto for provision of the manuscript ahead of time for my review.

Doctor Azakie and his colleagues have presented an outstanding series of 34 patients over a 20-year period with isolated ruptured sinus of Valsalva aneurysms due to congenital defects and congenital sinus of Valsalva aneurysms with 0% mortality. For a large center such as Toronto to have only between 1 and 2 patients per year from both their adult and pediatric hospitals speaks to the rarity of this defect and how infrequent the average cardiac surgeon is likely to encounter this defect during his career.

They are to be commended for limiting their analysis to the rupture of a single sinus of Valsalva aneurysm and not combining multiple etiologies for sinus of Valsalva aneurysms, including Marfan’s with multiple sinus involvement, trauma, syphilis, and primary endocarditis into a single series as in most other reports.

I would like to ask Dr Azakie about his definition of a sinus of Valsalva aneurysm. In particular, how he has separated the sinus of Valsalva aneurysm and VSD from the spectrum of isolated aortic valve prolapse with VSD. In my review of the literature and review of the pathology, I think these may represent a spectrum of the same congenital abnormality. I think it is useful to think of sinus of Valsalva aneurysm as a spectrum between an isolated sinus of Valsalva aneurysm without ventricular septal defect, on one end, and ventricular septal defect with prolapse of the aortic cusp, on the other extreme. A sinus of Valsalva aneurysm and ventricular septal defect with or without prolapse of the cusp would be an intermediate defect.

The Toronto series has a somewhat unusually high incidence of aortic insufficiency, with 70% of their patients experiencing some degree of aortic insufficiency and 30% having moderate to severe insufficiency. Many (32%) of their patients required surgical intervention on the aortic valve at the time of aneurysm repair, with 14 out of 34 patients being repaired through the aorta only without opening the chamber of penetration.

I have three questions for the authors. First, what is their definition of sinus of Valsalva aneurysm. Specifically, what is the distinction between sinus of Valsalva aneurysm and prolapse of the aortic valve with VSD?

Second, do you currently prefer primary repair with a patch through both the aorta and through the chamber into which the aneurysm penetrates or do you approach it through the aorta only?

Finally, I would like to ask the authors what they feel about surgical repair of nonruptured sinus of Valsalva aneurysms.

DR AZAKIE: Thank you for reviewing the paper, Dr Ring, and for your comments. With regards to the first question about the definition of ruptured sinus of Valsalva aneurysm, we limited our review to those patients in whom we thought and in whom the pathological findings revealed that the aneurysm was of congenital origin. Patients with Marfan’s syndrome, as you mentioned, previous surgery, trauma, or infection were excluded. The patients in this series had a ruptured sinus of Valsalva aneurysm limited to one aortic sinus. Patients with aortic-LV tunnel were excluded.

With regards to the question about aortic insufficiency, it is true that the incidence was relatively high in our patient population. About 70% of our patients did have some degree of aortic insufficiency, and this may be related to the recent use of transesophageal echocardiography and our increased ability to detect mild or even trace forms of aortic insufficiency. Most of the patients had mild or less than mild aortic insufficiency.

With regards to the question about repair technique, we currently approach the fistula through the aortic root as well as the exit chamber, and I would say that the preferred approach to repairing the defect would be to use a patch. Primary buttress closure in addition to patch closure may be useful, but I think the use of a patch is important because the rupture hole only marks a small area of where the elastic deficiency is in fact present within the sinus.

With regards to the question about repair of nonruptured sinus of Valsalva aneurysms, our current practice is to repair them if they produce symptoms. Asymptomatic aortic sinus aneurysms are repaired if they are large. Thank you.

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