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Ann Thorac Surg 2000;70:1696-1698
© 2000 The Society of Thoracic Surgeons

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Case report

Surgical repair of extracardiac unruptured acquired valsalva aneurysms

^a Department of Thoracic and Cardiovascular Surgery, Mie University School of Medicine, Mie, Japan

Address reprint requests to Dr Shimono, Department of Thoracic and Cardiovascular Surgery, Mie University School of Medicine, 2-174 Edobashi, Tsu, Mie 5148507, Japan
e-mail: simono-t{at}clin.medic.mie-u.ac.jp

	Abstract

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Two cases of extracardiac unruptured Valsalva aneurysms due to rare causes are reported. One patient had been suffering from hyper eosinophilic syndrome. Operative corrections consisted of total replacement of the aortic root. The other patient had an aneurysm of just noncoronary sinus of Valsalva and a dilated ascending aorta due to cystic mucoid degeneration. Replacement of the ascending aorta with patch closure for the aneurysm was successfully performed.

	Introduction

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Sinuses of Valsalva aneurysms are usually congenital and often rupture into the adjacent cardiac chambers. Reports concerning unruptured extracardiac aneurysms of the sinuses of Valsalva are very rare. We report here 2 rare surgical cases of aortic root replacement and replacement of the ascending aorta with patch closure for the aneurysms of the sinuses of Valsalva.

	Case reports

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Patient 1
A 53-year-old woman was admitted to Mie University Hospital for chest pain on exertion. She had been suffering from hyper eosinophilic syndrome for several years. Two weeks after admission, laboratory studies revealed a white blood cell count of 23,160/mm³, and eosinophils accounted for 75% of them. Since she was treated with steroid, the white blood cell count and the ratio of eosinophils gradually decreased.

Aortography demonstrated a large unruptured aneurysm of the left aortic sinus (Fig 1), and mild aortic regurgitation. Coronary arteriograms demonstrated multiple lesions of ectasia in the right coronary artery. The patient was referred to us for surgical treatment. A 7 x 6 cm aneurysm bulged toward the left side of the aorta, posterior to the main trunk of the pulmonary artery. The orifice of the aneurysm was 3 x 2 cm wide and there was no thrombus in the aneurysmal cavity. The right coronary sinus was also dilated 2 x 3 cm in size. An old thrombus was found at the right coronary artery ostium.

View larger version (121K): [in this window] [in a new window]   Fig 1. Preoperative aortography. All three aortic sinuses were dilated and the left aortic sinus was the most dilated with a diameter of 7 cm (Patient 1).

Postoperative angiograms obtained 1 month after the operation showed normal filling of the coronary arteries, but the multiple lesions of ectasiae persisted (Fig 2). The postoperative course was uneventful. Pathologic examination revealed inflammatory change associated with infiltration of eosinophils of the ascending aorta and degeneration of the aortic valve.

View larger version (90K): [in this window] [in a new window]   Fig 2. Postoperative coronary arteriograms demonstrating multiple lesions of ectasia in all the coronary arteries (Patient 1).

Aortography disclosed a large unruptured aneurysm of the noncoronary sinus, which protruded toward the right atrium and mild aortic regurgitation. The patient was referred to us for surgical treatment. A 5 x 4 cm aneurysm protruded toward the right atrium and adhered to the posterior wall of the right atrium solidly. Incision of the aneurysm wall showed a 2 x 3 cm orifice of the noncoronary sinus. The aortic valve was normal but the ascending aorta was dilated, being 5 cm in diameter. There was no dilatation of the aortic annulus. The noncoronary sinus and ascending aorta was reconstructed with a Dacron (C.R. Bard, Haverhill, PA) patch and 29 mm Hemashield graft.

The patient recovered uneventfully and was discharged on the 28th postoperative day. Pathologic examination showed cystic mucoid degeneration in the wall of the aneurysm.

	Comment

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Extracardiac, isolated, unruptured aneurysms of the sinuses of Valsalva are extremely rare, and this type of aneurysm may result in serious anatomic or physiologic derangement [1]. Compression of the left coronary artery by the aneurysm is an uncommon complication of this malformation and may cause coronary insufficiency [2]. Considering the risk of these complications, some authors have advocated elective repair of the unruptured aneurysm, even if asymptomatic and detected incidentally. Our first patient often felt chest pain before the operation, but she became symptom-free after the operation. We supposed that her chest pain was due to two factors; one was oppression of the aneurysm of the left coronary sinus of Valsalva, and the other was the thrombus present in the ostium of the right coronary artery which was confirmed during the operation.

Operative successful repair of extracardiac, unruptured, Valsalva aneurysms has been reported in 21 cases, to our knowledge. Of them, acquired aneurysm of the sinuses of Valsalva was found in 3 cases: reported by DeBakey and Lawrie in 1979 [3], Sakai and coworkers in 1994 [4], and Frank and associates in 1997 [5]. In 2 of the 3 cases, inflammatory change of unknown origin were found in the aortic wall of the aneurysm. In our first patient, who had hyper eosinophilic syndrome, infiltration of mononuclear cells and eosinophilic cells were detected in the wall of the aneurysm and part of the aortic valve.

The other patient had an isolated, unruptured aneurysm of the noncoronary sinus, and the ascending aorta of this patient was 5 cm in diameter. Pathological examination revealed cystic mucoid degeneration of the aortic wall. Frank and colleagues [5] reported a case of acquired Valsalva aneurysm of the right coronary sinus associated with cystic medial necrosis. They performed aortic root replacement for severe aortic insufficiency and annuloaortic ectasia. Although our second case presented with a condition similar to this case in some points, there was no annuloaortic ectasia in our patient.

In conclusion, extracardiac, unruptured Valsalva aneurysms should be surgically repaired, even if asymptomatic, considering these severe complications. An operative procedure for this type of aneurysm should be carefully selected after confirming the extent of the abnormal lesion during the operation.

	References

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1. Mayer J.H., III, Holder T.M., Canent R.V. Isolated, unruptured sinus of Valsalva aneurysm. J Thorac Cardiovasc Surg 1975;69:429-431.[Abstract]
2. Brandt J., Jogi P., Luhrs C. Sinus of Valsalva aneurysm obstructing coronary arterial flow. Eur Heart J 1985;6:1069-1073.[Abstract/Free Full Text]
3. DeBakey M.E., Lawrie G.M. Aneurysm of sinus of Valsalva with coronary atherosclerosis. Successful surgical correction. Ann Surg 1979;189:303-305.[Medline]
4. Sakai H., Lee T., Kajiyama H., et al. A case of unruptured aneurysm of the sinus of Valsalva associated with severe aortic regurgitation. J Cardiol 1994;24:147-152.
5. Frank A.P., Bartley P.G., Robert L.K. Massive sinus of Valsalva aneurysm presenting with coronary insufficiency. Ann Thorac Surg 1997;64:1475-1476.[Abstract/Free Full Text]

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This Article Abstract Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Koji Onoda Isao Yada Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Yasuda, F. Articles by Yada, I. Search for Related Content PubMed PubMed Citation Articles by Yasuda, F. Articles by Yada, I.