ATS
HOME HELP FEEDBACK SUBSCRIPTIONS ARCHIVE SEARCH TABLE OF CONTENTS
QUICK SEARCH:   [advanced]


     

Ann Thorac Surg 2008;86:640-643. doi:10.1016/j.athoracsur.2008.01.081
© 2008 The Society of Thoracic Surgeons
This Article
Right arrow Abstract Freely available
Right arrow Full Text (PDF)
Right arrow Alert me when this article is cited
Right arrow Alert me if a correction is posted
Right arrow Citation Map
Services
Right arrow Email this article to a friend
Right arrow Similar articles in this journal
Right arrow Similar articles in PubMed
Right arrow Alert me to new issues of the journal
Right arrow Add to Personal Folders
Right arrow Download to citation manager
Right arrow Author home page(s):
Mitsuhiro Yamamura
Yuji Miyamoto
Right arrow Permission Requests
Citing Articles
Right arrow Citing Articles via HighWire
Right arrow Citing Articles via Google Scholar
Google Scholar
Right arrow Articles by Fukui, S.
Right arrow Articles by Miyamoto, Y.
Right arrow Search for Related Content
PubMed
Right arrow PubMed Citation
Right arrow Articles by Fukui, S.
Right arrow Articles by Miyamoto, Y.
Related Collections
Right arrow Great vessels

Case Reports

Successful Repair of Unruptured Aneurysm of the Right Sinus of Valsalva

Shinya Fukui, MD, PhD, Masataka Mitsuno, MD, PhD, Mitsuhiro Yamamura, MD, PhD, Hiroe Tanaka, MD, Yasuhiko Kobayashi, MD, PhD, Masaaki Ryoumoto, MD, PhD, Yuji Miyamoto, MD, PhD*

Department of Cardiovascular Surgery, Hyogo College of Medicine, Hyogo, Japan

Accepted for publication January 28, 2008.

* Address correspondence to Dr Miyamoto, Department of Cardiovascular Surgery, Hyogo College of Medicine, 1-1, Mukogawa-chou, Nishinomiya, Hyogo, 663–8501, Japan (Email: y-miyamo{at}hyo-med.ac.jp).


   Abstract
Top
 Abstract
Introduction
 Comment
 References
 
Patch closure of the orifice of an aneurysm is a common operation for sinus of Valsalva aneurysms. Recently, there have been reports of aortic valve–sparing operations for multisinus of Valsalva aneurysms. However, repair would be difficult if only one sinus of Valsalva was dilated. We report a patient with a single unruptured sinus of Valsalva aneurysm successfully treated using the patch repair technique.


   Introduction
Top
 Abstract
 Introduction
Comment
 References
 
Sinus of Valsalva aneurysms are relatively uncommon, occurring in 0.15% to 1.5% of patients who have undergone cardiopulmonary bypass [1]. The indication for surgical repair is controversial at the time of diagnosis. As well, the repair technique will depend on how many sinuses are dilated, whether the aneurysm is ruptured, and whether the aneurysm has an orifice. We report a case of a single unruptured sinus of Valsalva aneurysm that did not have an orifice.

A 38-year-old woman was referred to our institution for investigation of a diastolic heart murmur detected by a general practitioner during a physical examination. She had no overt symptoms. An echocardiogram showed severe aortic regurgitation and enlargement of the sinus of Valsalva (diameter, 52 mm) without a ventricular septal defect. A chest computed tomography scan demonstrated an aneurysm of the right sinus of Valsalva and a right coronary artery that originated from the aneurysm. We recommended surgical repair, and the patient provided informed consent.

The intraoperative examination revealed a large, extremely thin-walled aneurysm of the right coronary sinus of Valsalva and a depressed right coronary artery (Fig 1). Cardiopulmonary bypass was established after placing an arterial cannula to the ascending aorta and direct bicaval cannulations. The ascending aorta was then clamped and an aortotomy made transversely and longitudinally. The aorta above the left coronary sinus of Valsalva and the left coronary sinus of Valsalva were normal. The aorta above the noncoronary sinus of Valsalva was enlarged, but the noncoronary sinus of Valsalva was normal. The aorta above the right coronary sinus of Valsalva, the right coronary sinus of Valsalva, and the aortic annulus of the right coronary cusp were all enlarged, resulting in severe aortic regurgitation. The noncoronary and right coronary cusps were thickened and shortened (Fig 2A); therefore, repair of the aortic valve was considered very difficult.


Figure 1
View larger version (131K):
[in this window]
[in a new window]

  		Fig 1. An intraoperative photo shows the gross appearance of a large aneurysm (AN) of the right coronary sinus of Valsalva. (RCA = right coronary artery.)

 

Figure 2
View larger version (78K):
[in this window]
[in a new window]

  		Fig 2. (A) Left, the aorta above the noncoronary sinus of Valsalva is enlarged. The aorta above the right coronary sinus of Valsalva, the right coronary sinus of Valsalva and the aortic annulus of right coronary cusp are enlarged. Right, a dotted line indicates the dilated Valsalva sinus. (B) The stitches above the right coronary cusp and half the noncoronary cusp that passed through the sewing cuff and the trimmed Hemashield graft are tied down. (C) The remaining patch is anastomosed to the sinotubular junction of the noncoronary cusp and the peripheral edge of the aortotomy. The right coronary artery is reconstructed. (LCC = left coronary cusp; NCC = noncoronary cusp; RCA = right coronary artery; RCC = right coronary cusp.)

 
The strategy for surgical management was decided intraoperatively. We resected the aneurysm and replaced the aortic valve. Aortic valve replacement with a 21-mm Sorin Bicarbon (Sorin Biomedica, Saluggia, Italy) slimline valve and patch repair with a Hemashield (Boston Scientific, Natick, MA) graft were achieved. Thirteen pairs of horizontal mattress stitches were passed from the ventricular side of the annulus to the aortic surface and then through the sewing cuff of the prosthetic valve. The 4 sutures above the left coronary annulus and 3 half-sutures above the noncoronary annulus were tied down because these Valsalva sinuses were normal. The remaining 6 stitches were passed through the trimmed Hemashield graft (20 x 40 mm) and then tied down (Fig 2B). The remaining patch was approximated and anastomosed to the sinotubular junction of the noncoronary cusp and the peripheral edge of the aortotomy with a 3-0 Prolene (Ethicon, Somerville, NJ) continuous suture. The Hemashield graft was carefully anastomosed vertically to the valve sewing ring to prevent the interference of the graft with the valve disc motion.

The trimmed right coronary ostium was anastomosed to the Hemashield graft with a 6-0 Prolene continuous suture (Fig 2C). The right coronary artery (RCA) was elongated because the aneurysm had pushed up the RCA for a long time; therefore, the length of RCA was long enough to reach the Hemashield graft. Eventually, the RCA was easily reconstructed without tension. The Hemashield graft was loosely wrapped by the aortic aneurysmal wall to decrease postoperative plasma leakage from the Hemashield graft. The aorta was declamped and cardiopulmonary bypass uneventfully terminated. There was no transfusion.

The patient's postoperative course was uneventful, and she was discharged on day 21. Histologic examination revealed that the aortic media was diffusely necrotized and the elastic fiber of the media severely destroyed.


   Comment
Top
 Abstract
 Introduction
 Comment
References
 
Sinus of Valsalva aneurysms are rarely detected if there is no heart murmur of aortic regurgitation or a ventricular septal defect. Furthermore, sinus of Valsalva aneurysms rarely present with symptoms unless rupture occurs. The distribution of aneurysmal sites has been stated to be approximately 70% right coronary sinus, 29% noncoronary sinus, and just 1% for the left coronary sinus [2]. Thus, there have been few reported cases of unruptured sinus of Valsalva aneurysms that have presented with conduction disturbances, myocardial ischemia, right ventricular failure, pulmonary insufficiency, or symptomatic cardiac dysfunction [3]. These aneurysms may be congenital, due to a deficiency in the muscular and elastic tissues at the base of the aorta, or acquired after infective endocarditis, atherosclerosis, or aortic dissection [4]. Our case appears to have been congenital because the aortic media was diffusely destroyed.

The surgical approach for repair depends on various factors, such as whether the aneurysm is ruptured, the need to repair or replace the aortic valve, and the presence or absence of an orifice of the aneurysm. The operative procedure chosen is patch closure of the orifice of the aneurysm in most cases [5]. Patch closure was not available in our case because the aneurysm had no orifice.

Successful aortic valve–sparing operations, such as remodeling or reimplantation procedures for sinus of Valsalva aneurysms, have recently been reported [6, 7]. The reported cases show trivial or mild aortic regurgitation with normal aortic valves and 2 or 3 sinuses of Valsalva enlarged. A remodeling or reimplantation procedure would be suitable for all dilated Valsalva walls with trivial to moderate aortic regurgitation [6]. Our patient, however, had severe aortic regurgitation with thickened noncoronary and right coronary cusps and a single dilated annulus and sinus. Therefore, an aortic valve–sparing operation, such as remodeling or reimplantation, was not undertaken in this patient. It would be difficult to plicate only one dilated sinus with an aortic valve–sparing procedure.

In a previous report, distorted sinuses of Valsalva were replaced by a patch, and an ascending aorta was replaced by a tube graft without aortic valve replacement [8]. However, the patch technique in those cases is more complicated than our patch repair technique because we used only 1 patch graft and did not need a tube graft.

In conclusion, we report a single patch repair technique for a single unruptured sinus of Valsalva aneurysm. This patch repair technique is a useful and safe option for an unruptured single sinus of Valsalva aneurysm without an orifice for the aneurysm.


   References
Top
 Abstract
 Introduction
 Comment
 References
 

  1. Moustafa S, Mookadam F, Cooper L, et al. Sinus of Valsalva aneurysms-47 years of a single center experience and systematic overview of published reports Am J Cardiol 2007;99:1159-1164.[Medline]
  2. Roberts WC. Congenital cardiovascular abnormalities usually "silent" until adulthood: morphologic features of the floppy mitral valve, valvular aortic stenosis, discrete subvalvular aortic stenosis, hypertrophic cardiomyopathy, sinus of Valsalva aneurysm, and the Marfan syndrome Cardiovasc Clin 1979;10:407-453.[Medline]
  3. Bulkley BH, Hutchins GM, Ross RS. Aortic sinus of Valsalva aneurysms simulating primary right-sided valvular heart disease Circulation 1975;52:696-699.[Abstract/Free Full Text]
  4. Marques KM, De Cock CC, Visser CA. Isolated unruptured aneurysm of the right sinus of Valsalva causing right ventricular outflow obstruction Heart 1999;81:447-448.[Free Full Text]
  5. Wang Z, Zou C, Li D, et al. Surgical repair of sinus of Valsalva aneurysm in asian patients Ann Thorac Surg 2007;84:156-160.[Abstract/Free Full Text]
  6. Akashi H, Tayama E, Tayama K, Kosuga T, Takagi K, Aoyagi S. Remodeling operation for unruptured aneurysms of three sinuses of Valsalva J Thorac Cardiovasc Surg 2005;129:951-952.[Free Full Text]
  7. Hughes GC, Swaminathan M, Wolfe WG. Reimplantation technique (David operation) for multiple sinus of Valsalva aneurysms Ann Thorac Surg 2006;82:e14-e16.[Abstract/Free Full Text]
  8. Urbanski PP. Valve-sparing aortic root repair with patch technique Ann Thorac Surg 2005;80:839-844.[Abstract/Free Full Text]



This article has been cited by other articles:


Home page
 Ann. Thorac. Surg.Home page
Y. Nishimura, K. Honda, K. Toguchj, S. Uchita, and Y. Okamura
A Rare Case of an Extracardiac Unruptured Aneurysm of the Sinus of Valsalva in a Patient With Single Coronary Artery
Ann. Thorac. Surg., September 1, 2011; 92(3): 1113 - 1115.
[Abstract] [Full Text] [PDF]

Home page
 Ann. Thorac. Surg.Home page
M. H. Hines and N. D. Kon
Sinus of Valsalva Aneurysm Repair With Partial Allograft, and 10-Year Follow-Up
Ann. Thorac. Surg., November 1, 2010; 90(5): 1701 - 1703.
[Abstract] [Full Text] [PDF]

Home page
 RadioGraphicsHome page
A. O. Bricker, B. Avutu, T.-L. H. Mohammed, E. E. Williamson, I. S. Syed, P. R. Julsrud, P. Schoenhagen, and J. Kirsch
Valsalva Sinus Aneurysms: Findings at CT and MR Imaging
RadioGraphics, January 1, 2010; 30(1): 99 - 110.
[Abstract] [Full Text] [PDF]

This Article
Right arrow Abstract Freely available
Right arrow Full Text (PDF)
Right arrow Alert me when this article is cited
Right arrow Alert me if a correction is posted
Right arrow Citation Map
Services
Right arrow Email this article to a friend
Right arrow Similar articles in this journal
Right arrow Similar articles in PubMed
Right arrow Alert me to new issues of the journal
Right arrow Add to Personal Folders
Right arrow Download to citation manager
Right arrow Author home page(s):
Mitsuhiro Yamamura
Yuji Miyamoto
Right arrow Permission Requests
Citing Articles
Right arrow Citing Articles via HighWire
Right arrow Citing Articles via Google Scholar
Google Scholar
Right arrow Articles by Fukui, S.
Right arrow Articles by Miyamoto, Y.
Right arrow Search for Related Content
PubMed
Right arrow PubMed Citation
Right arrow Articles by Fukui, S.
Right arrow Articles by Miyamoto, Y.
Related Collections
Right arrow Great vessels

HOME HELP FEEDBACK SUBSCRIPTIONS ARCHIVE SEARCH TABLE OF CONTENTS
ANN THORAC SURG ASIAN CARDIOVASC THORAC ANN EUR J CARDIOTHORAC SURG
J THORAC CARDIOVASC SURG ICVTS ALL CTSNet JOURNALS