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Ann Thorac Surg 2004;78:2187
© 2004 The Society of Thoracic Surgeons

Images in cardiothoracic surgery

Ruptured Left Coronary Sinus of Valsalva Aneurysm Into the Left Ventricle

Takayuki Saito, MDa, Miki Asano, MDa, Michiko Ishida, MDa, Shigeru Sasaki, MDa, Norikazu Nomura, MDa, Tomohiko Ukai, MDa, Akira Mishima, MDa,*

a Department of Cardiovascular Surgery, Nagoya City University Graduate School of Medical Sciences, Nagoya, Japan

* Address reprint requests to Dr Mishima, Department of Cardiovascular Surgery, Nagoya City University Graduate School of Medical Sciences, 1 Kawasumi, Mizuho, Nagoya 467-8601, Japan
mishima{at}med.nagoya-cu.ac.jp

Ruptured aneurysm originating from the left coronary sinus toward the left ventricle (LV) is an extremely rare problem and the incidence was reported as 1.8% of all ruptured sinus Valsalva aneurysms [1]. This can cause severe aortic regurgitation, coronary insufficiency, and paroxysmal ventricular fibrillation [2].

A 59-year-old Japanese male presented with exertional dyspnea. Chest roentogenogram revealed bilateral pleural effusion and cardiomegaly. Two hours after his admission he required resuscitation because of sudden cardiopulmonary arrest. A two-dimensional echocardiogram demonstrated severe aortic regurgitation with compensated LV contractility. Initially he was treated with intensive medical care for congestive heart failure. Definitive diagnosis was confirmed on left-sided catheterization. The aortogram showed the "wind-sock" appearance of the aneurismal sac arising from the left coronary sinus extruding into the LV (arrow in Fig 1). The left coronary artery was intact (arrowhead in Fig 1) and no associated lesion, such as ventricular septal defect, was identified.



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  		Fig 1.
 
Standard cardiopulmonary bypass was used during repair. The aneurysm was exposed through an oblique aortotomy. The aortic valvular ring at the left coronary sinus had detached completely from the aortic wall. The sac tightly adhered to the free wall of the LV and the bottom of the sac had perforated (asterisk in Fig 2). The left coronary cusp, valvular ring (arrowheads in Fig 2), and free wall of the aneurysmal sac were removed together. In order to obtain firm anchorage of a mechanical valve, mattress sutures with Teflon pledgets at the defect of valvular ring were directly placed on the aortoventricular junction where aneurismal wall adhering to the endocardium had turned into scar tissue. Histologic examination showed an accumulation of inflammatory cells (not only mononuclear cells but also neutrophiles) implying that a possible cause of aneurysmal formation was an infective endocarditis although any organisms could be identified from these specimens.



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  		Fig 2.
 
References

  1. Au WK, Chiu SW, Mok CK, Lee WT, Cheung D, He GW. Repair of ruptured sinus of valsalva aneurysm: determinants of long-term survival. Ann Thorac Surg. 1998;66:1604–1610[Abstract/Free Full Text]
  2. Glock Y, Ferrarini JM, Puel J, Fauvel JM, Bounhourne JP, Puel P. Isolated aneurysm of the left sinus of Valsalva. Rupture into the left atrium, left ventricle and dynamic coronary constriction. J Cardiovasc Surg (Torino). 1990;31:235–238[Medline]



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F. Yan, Q. Huo, J. Qiao, V. Murat, and S.-F. Ma
Surgery for Sinus of Valsalva Aneurysm: 27-Year Experience with 100 Patients
Asian Cardiovasc Thorac Ann, October 1, 2008; 16(5): 361 - 365.
[Abstract] [Full Text] [PDF]

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