Ann Thorac Surg 2006;81:350-352
© 2006 The Society of Thoracic Surgeons
Case report
Novel Repair for Late Posttraumatic Aortic Valve Injury and Root Pseudoaneurysm
Andrea Venturini, MD, PhD
a
,
*
,
Raimondo Ascione, MD, MCh
b
,
Franco Ciulli, MD
b
,
Elvio Polesel, MD
a
,
Roberto Moretti, MD
a
,
Gianni D. Angelini, MD, MCh
b
,
Claudio Zussa, MD, PhD
a
a Department of Cardiac Surgery, Ospedale Civile Umberto I, Venezia Mestre, Italy
b Bristol Heart Institute, Bristol Royal Infirmary, Bristol, United Kingdom
Accepted for publication September 3, 2004.
* Address correspondence to Dr Venturini, Unità Operativa di Cardiochirurgia, Ospedale Civile Umberto I, Via Circonvallazione 50, Venezia Mestre, 30174 Italy (Email: andrventurini{at}libero.it).
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Abstract
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We report a case of posttraumatic aortic valve regurgitation and pseudoaneurysm of the aortic root diagnosed 22 months after a road traffic accident. The surgical treatment consisted of exclusion of the pseudoaneurysm with direct closure of the entry tear in the right coronary sinus followed by insertion of a Toronto stentless prosthesis (St. Jude Medical, St. Paul, MN). This surgical approach aimed to cover the repaired entry tear ensuring exclusion of the site. Recovery was uneventful and 12 month follow-up was unremarkable.
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Introduction
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Traumatic aortic valve regurgitation and pseudoaneurysm of the aortic root are rare complications of road traffic accidents [1]. There is very little in the literature on simultaneous occurrence of traumatic pseudoaneurysm of the aortic root and aortic valve insufficiency [1].
We report a case of concomitant severe aortic valve regurgitation and pseudoaneurysm of the aortic root diagnosed 22 months after road traffic accidents treated with direct closure of the pseudoaneurysm neck and subsequent insertion of a stentless aortic valve.
An otherwise healthy 26-year-old man sustained blunt trauma caused by rapid deceleration in a motorbike road accident. The patient was taken to the accident and emergency department and blood pressure, heart rate, electrocardiogram, and chest roentgenogram were unremarkable on examination. Transthoracic echocardiogram showed mild aortic regurgitation and no pericardial effusion. The patient suffered several injuries to his face requiring multiple staged corrective surgery.
Nine months after the road traffic accidents the patient complained of moderate shortness of breath on exercise. A transthoracic echocardiogram showed moderate aortic regurgitation and moderate dilatation of the aortic root. The findings were not considered to be an indication for surgery at that stage.
One year later the patient's condition deteriorated. Cardiac catheterization and echocardiogram showed severe aortic regurgitation and a saccular aneurysm of the aortic root requiring operation (Fig 1). After median sternotomy, cardiopulmonary bypass was established and the aortic valve and root were explored through a transverse aortotomy. There was a 20-mm pseudoaneurysm of the aortic root originating from a tear in the right sinus of Valsalva below the ostium of the right coronary artery. There was also a circular shaped tear (7 to 8 mm) in the right coronary cusp with thickened edges, suggestive of chronic fibrotic degeneration (Fig 2). The diameters of the aortic annulus and of the sinotubular junction were 24 and 25 mm, respectively. These findings excluded the possibility of aortic valve repair. Therefore the native aortic valve was excised and the neck of the pseudoaneurysm was closed with two 4-0 Prolene pericardial pledgeted mattress-stitches (Ethicon, Somerville, NJ). Next, a size 25-mm Toronto stentless valve (St. Jude Medical, St. Paul, MN) was inserted with the aim of excluding the entry of the pseudoaneurysm (Fig 3). The aortotomy was then closed and the patient was easily weaned off the cardiopulmonary bypass.
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Fig 2. Intraoperative view of the large tear in the right coronary leaflet (blue arrow) and the rupture in the right sinus of Valsalva (black arrow).
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Fig 3. Schematic operative technique: (A and B) closure of the ostium of the pseudoaneurysm with two 4-0 Prolene interrupted pericardial pledgeted mattress stitches (Ethicon, Somerville, NJ). (C) Insertion of the stentless valve covering the origin of the pseudoaneurysm to ensure its exclusion.
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Intraoperative transesophageal echocardiography showed no blood flow in the pseudoaneurysm and a well functioning and competent stentless valve. Recovery was unremarkable and the patient was discharged home on postoperative day 6. Transthoracic echocardiogram performed at 3 and 12 months after the surgery continued to show well functioning stentless valve and no recurrence of the pseudoaneurysm.
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Comment
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Deceleration injuries of the aorta may result in tears that can potentially lead to catastrophic hemorrhage. The tear site is most often at the aortic isthmus with injuries of the aortic root being rare [2]. It has been postulated that the mechanism of aortic valve injury may be due to a sudden increase of pressure during the beginning of diastole. Although the pressure is low in the empty left ventricle, the high aortic pressure may induce an abnormal damaging stress if the valve is competent [3]. This increase of pressure is a consequence of blunt trauma or deceleration in high-speed accidents [3]. However, little is known about the true mechanism leading to aortic root pseudoaneurysms.
Our case presented 22 months after a road traffic accident with a combined aortic valve and aortic root lesion. We speculate that the road traffic accident initially determined a minimal degree of localized injuries that extended with time, leading to late severe aortic regurgitation and pseudoaneurysm formation because the patient only presented with a moderate degree of aortic regurgitation and moderate dilatation of the aortic root at 9 months.
Consideration should be given to the choice of operation for a ruptured aortic valve (ie, repair or replacement). After an extensive review of the literature, Meunier [2] concluded that the indications for conservative surgery include a simple tear, avulsion of one cusp, or one avulsed commissure, whereas prosthetic valve replacements should be limited to complex or multiple lesions in which most of the attempted repairs have been unsuccessful in the short-term or mid-term.
Our solution of replacing the aortic valve with a stentless bioprosthesis was determined by a personal preference of the patient preoperatively and by the favorable intraoperative findings. The position of the pseudoaneurysm neck was such that after direct repair it was possible to ensure its exclusion by covering it with the bioprosthesis itself. Aortic root pseudoaneurysms have usually been approached either with a patch repair [4] or with root replacement [5]. However, the technique reported herein is much simpler and is as effective as an aortic root replacement.
We would like to stress that our surgical solution has been possible both because of favorable anatomy and because the direct closure of the aortic tear was considered safe due to good tissue quality. More conventional surgical approaches consisting of aortic root replacement with either a tissue root or a composite prosthesis should otherwise be considered.
In conclusion, we report a novel way of repairing concomitant aortic valve injury and sinus of Valsalva pseudoaneurysms by using a stentless aortic valve. This solution may be an effective and simple surgical option in the presence of favorable surgical presentation.
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References
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- Penderleath D. Cause of death from rupture of one of semilunar valves of the aorta London Medical Gazette 1830;7:109.
- Meunier J-P, Berkane N, Lopez S, et al. Traumatic aortic regurgitationaortic valvuloplasty controlled by aortoscopy. J Heart Valve Dis 2001;10:784-788.[Medline]
- Bright EF, Beck CS. Nonpenetrating wounds of the heartclinical and experimental studies. Am Heart J 1935;10:293-297.
- Murray EG, Minami K, Kortke H, et al. Traumatic sinus of Valsalva fistula and aortic valve rupture Ann Thorac Surg 1993;55:760-761.[Abstract/Free Full Text]
- Tamura K, Nakahara H, Furukawa H, et al. Traumatic aortic regurgitation with ascending aortic aneurysmreport of a case. Kyobu Geka 2003;56(3):225-227.[Medline]
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Abstract
Introduction
