Ann Thorac Surg 2005;79:341-343
© 2005 The Society of Thoracic Surgeons
Case report
Surgical Repair of Postoperative Left Sinus of Valsalva Aneurysm Dissecting Into the Interventricular Septum
Veysel Kutay, MDa,*,
Hasan Ekim, MDa,
Cevat Yakut, MDa
a Department of Cardiovascular Surgery, Yüzüncü Yil University, School of Medicine, Van, Turkey
Accepted for publication August 6, 2003.
* Address reprint requests to Dr Kutay, Department of Cardiovascular Surgery, Faculty of Medicine, Yüzüncü Yil University, 65200, Van, Turkey
vkutay{at}yahoo.com
 |
Abstract
|
|---|
We describe the dissection of the interventricular septum by unruptured aneurysm of the left sinus of Valsalva in a patient who had undergone aortic valve replacement for rheumatic aortic valve insufficiency 5 years previously. The patient had worn a permanent pacemaker for 1 year to manage complete atrioventricular block. Sufficient information was provided by echocardiography and aortography to confirm the diagnosis. Operative correction consisted of obliteration of the aneurysm sac and closure of the outward orifice with a Dacron patch from the side of the aortic sinus.
|
Introduction
|
|---|
Sinus of Valsalva aneurysms (SVAs) usually arise from the right or noncoronary sinus, and the most common manifestation is a rupture into the right ventricle or atrium. The congenital aneurysms of the sinus of Valsalva are more common than acquired aneurysms, and acquired aneurysms of the left sinus of Valsalva are rare [1–3]. Acquired aneurysms are caused by a deficiency of the aortic media, which may result from trauma, endocarditis, Marfan's syndrome, syphilis, and senile type of dilation [2, 3]. We report an unruptured SVA that developed after aortic valve replacement, originated from the left sinus, and dissected into the interventricular septum.
A 38-year-old man, who had undergone aortic valve replacement (25-mm Carbomedics prosthesis; Sulzer Carbomedics, Austin, TX) 5 years previously in another hospital because of severe rheumatic aortic valve insufficiency, was admitted to our hospital 1 year ago because of fatigue and syncope. A permanent rate-adaptive DDD pacemaker device was implanted to manage complete atrioventricular block, and the patient was followed up periodically for 1 year with the diagnosis of SVA. There was no history or sign of infective endocarditis. Transthoracic and transesophageal echocardiography revealed a 4 x 2-cm SVA with a thin wall extending into the left ventricle outflow tract with splitting of the upper segment of the interventricular septum (Fig 1). Paravalvular leak, left ventricle outflow tract obstruction, and prosthesis dysfunction were not encountered. The diagnosis was confirmed by an aortic root angiogram. The compression or displacement of the left coronary artery by the aneurysm was not detected by coronary arteriography. Although the patient was asymptomatic, the operation was performed electively to prevent potential complications. Cardiopulmonary bypass was instituted by ascending aortic arterial and right atrial two-stage venous cannulation. Diastolic arrest and myocardial protection were supplied by retrograde hyperkalemic blood cardioplegia with moderate systemic hypothermia (30°C). The shape of the ascending aorta and aortic valve prosthesis were normal, but the right and noncoronary sinuses of Valsalva were slightly enlarged. A saccular fingerlike aneurysm (4 x 3 x 5 cm) was seen arising from the central part of the left coronary sinus of Valsalva just inferior to the left coronary ostium. The oval orifice of the aneurysm was situated between the annulus of the aortic valve and the left coronary ostium. The aneurysmal sac extended toward the interventricular septum below the right coronary sinus (Fig 2). The inner cavity of the aneurysm sac was obliterated by 3 interrupted and pledgeted horizontal mattress sutures. We acted carefully to avoid inadvertent injury of the left coronary artery. The outward orifice of the left sinus was closed with a 3 x 4-cm Dacron patch using 4–0 polypropylene suture. The patient was successfully weaned from cardiopulmonary bypass and discharged from the hospital without any complications on the 7th postoperative day.
View larger version (119K):
[in this window]
[in a new window]
|
Fig 1. Transthoracic echocardiography showing a 4 x 2-cm dissecting aneurysm of the interventricular septum just below the prosthetic aortic valve (arrows). (AO = aorta; LA = left atrial; LV = left ventricle.)
|
|
View larger version (112K):
[in this window]
[in a new window]
|
Fig 2. Operative photograph showing the orifice of the left sinus of Valsalva aneurysm extending toward the interventricular septum below the right coronary sinus, situated between the aortic annulus and left coronary ostium (arrows).
|
|
|
Comment
|
|---|
The clinical significance and manifestation of ruptured SVAs depend on their anatomic location and the amount of flow through the abnormal communication. Aneurysms of the right and noncoronary sinuses are seen much more frequently than aneurysms of the left sinuses, and usually rupture into the right atrium and the right ventricle, resulting in aortocardiac fistulas [1, 2]. However, unruptured SVAs are usually symptom-free. Aneurysm of the left coronary sinus, which is very rare, may protrude or rupture into the left ventricle, pulmonary artery, myocardium, and epicardium. Asian patients seem to be more prone to the development of this uncommon anomaly. If complications such as aortic insufficiency, coronary artery compression, left or right outflow tract obstruction, conduction abnormalities, infective endocarditis, mitral valve incompetence, and left-ventricle free wall or interventricular septum dissection are not present, most unruptured SVAs are identified incidentally [3–8]. Determination of the specific etiology of SVA may be difficult and various pathologic processes may effect the development. Atherosclerotic degenerative processes or traumatic or infective diseases are usually the cause of acquired SVAs, and only 1% to 10% of SVAs originate in the left coronary sinus [4, 5]. Although nonruptured SVAs remain silent, they may extend and cause more complicated and severe symptoms requiring more extensive surgical corrections. Takach and colleagues [4] suggested that the outcome of SVAs can be improved if an operation is performed in the absence of endocarditis, because 80% of operative deaths are related to the effects of preexisting active bacterial endocarditis. We did not find any sign of infection or history of infective endocarditis in our patient.
Dissection of interventricular septum as a complication of SVA is seen very rarely. In most reported series, the aneurysm originates from the right coronary sinus in 90% of cases [6–8] and aortic valve insufficiency usually accompanies dissection of the interventricular septum. Only minor annular aortic ectasia, not SVA, was detected during our patient's first operation. Four years later, a Valsalva aneurysm originating from the left sinus and extending toward the interventricular septum was diagnosed after the sudden onset of complete heart block. As in the present case, the most common feature of reported cases is the presence of atrioventricular conduction disturbances [6–8]. Choudhary and colleagues [7] reviewed 26 reported cases of SVAs dissecting into interventricular septum; more than 50% of patients had congestive heart failure (as a result of aortic regurgitation) and complete atrioventricular block. Direct pressure by the expanding aneurysm is considered responsible for atrioventricular dissociation and various types of bundle-branch blocks. In addition, the evidence of hemorrhage and low-grade inflammatory changes in conduction tissue near the aneurysm are possible causes of conduction disturbances. Although intramural rupture of a congenital aneurysm with subsequent formation of a hematoma, which represents a pseudoaneurysm, is thought to cause intraseptal extension [7], in our case SVA dissecting into interventricular septum was formed postoperatively and did not contain hematoma. The dissecting aneurysm of the interventricular septum may mimic aortic root abscess, but it differs from aortic root abscess in terms of clinical symptoms and pathologic changes. An accurate definition of the anatomic lesion and precise diagnosis were achieved by transthoracic echocardiography and aortic root angiography. Lijoi and colleagues [5] evaluated 19 previously reported cases in which an unruptured left SVA hindered coronary arterial flow. Forty-five percent of the aneurysms were acquired and only half of the patients underwent surgery (the first successful operation was performed in 1976) [5]. Although calcification of the SVA is rare, Bapat and colleagues [8] reported calcification extending along the annulus in 3 of 7 patients. The unfavorable effects of calcification include difficulty of direct suturing of the orifice, potential increase of paravalvular leak, and the late risk of dehiscence. Plication of the aneurysmal cavity with direct sutures and the closure of the mouth of the aneurysm with a patch is an effective and simple surgical technique. Resection of the sac is unnecessary and may damage the interventricular septum.
In conclusion, dissection of the interventricular septum is a very serious and rarely seen complication of SVAs that can be easily diagnosed by echocardiography and should be treated by early elective surgery, even in asymptomatic patients, to prevent poor prognosis.
|
References
|
|---|
- Kirklin JW, Barratt-Boyes BE. Congenital aneurysm of the sinus of Valsalva. Kirklin JW, Barratt-Boyes BE. Cardiac surgery. 2nd ed. New York: Churchill Livingstone; 1993. p. 825–839
- Goldberg N, Krasnow N. Sinus of Valsalva aneurysms. Clin Cardiol. 1990;13:831–836[Medline]
- Engel PJ, Held JS, Bel Kahn JVD. Echocardiographic diagnosis of congenital sinus of Valsalva aneurysm with dissection of the interventricular septum. Circulation. 1981;63:705–710[Abstract/Free Full Text]
- Takach TJ, Reul GJ, Duncan M, et al. Sinus of Valsalva aneurysm or fistula: management and outcome. Ann Thorac Surg. 1999;68:1573–1577[Abstract/Free Full Text]
- Lijoi A, Parodi E, Passerone GC, Scarano F, Caruso D, Ianetti VM. Unruptured aneurysm of the left sinus of Valsalva causing coronary insufficiency. Tex Heart Inst J. 2002;29:40–44[Medline]
- Wu Q, Xu J, Shen X, Wang D, Wang S. Surgical treatment of dissecting aneurysm of the interventricular septum. Eur J Cardiothorac Surg. 2002;22:517–520[Abstract/Free Full Text]
- Choudhary SK, Bhan A, Reddy SC, et al. Aneurysm of sinus of Valsalva dissecting into interventricular septum. Ann Thorac Surg. 1998;65:735–740[Abstract/Free Full Text]
- Bapat VN, Tendolkar AG, Khandeparkar J, et al. Aneurysms of sinus of Valsalva eroding into the interventricular septum: etiopathology and surgical considerations. Eur J Cardiothorac Surg. 1997;12:759–765[Abstract]
This article has been cited by other articles:
|
|
|
|
 
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]
|
|
|
Top
Abstract
Introduction
