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Ann Thorac Surg 2009;87:646. doi:10.1016/j.athoracsur.2008.06.073
© 2009 The Society of Thoracic Surgeons
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Wilson Y. Szeto
Joseph E. Bavaria
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Images in Cardiothoracic Surgery

Aortic Valve Commissural Fenestrations Due to Sinus of Valsalva Dilatation

Clifton C. Reade, MD*, Wilson Y. Szeto, MD, Joseph E. Bavaria, MD

Division of Cardiovascular Surgery, University of Pennsylvania, Philadelphia, Pennsylvania

* Address correspondence to Dr Reade, Division of Cardiovascular Surgery, University of Pennsylvania, 6 Silverstein, 3400 Spruce St, Philadelphia, PA 19104 (Email: clifton.reade{at}uphs.upenn.edu).

A 67-year-old man originally presented with left jaw and right shoulder pain and was ruled out for coronary artery disease. However, a transthoracic echocardiogram showed +3 aortic insufficiency and a 6-cm ascending aortic aneurysm. After presentation to our aortic diseases clinic, he was taken to the operating room for repair.

Intraoperative transesophageal echocardiography confirmed good ventricular function, +3 aortic insufficiency, and a 6-cm dilated ascending aortic aneurysm (Fig 1). The sinotubular junction was measured at 5.5 cm with the annulus at 3.0 cm. Standard cannulation techniques were used, and after cross clamping and cardioplegic arrest, the aorta was opened. Initial valvular inspection showed fenestrations at all three commissural connections to the sinus (Fig 2). A valve-sparing procedure was therefore abandoned, and the root was dissected for replacement.


Figure 1
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  		Fig 1.
 

Figure 2
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  		Fig 2.
 
While cooling to electrical standstill, a Medtronic Freestyle root (Medtronic Inc, Minneapolis, MN) was fashioned to the annulus after removal of the aortic leaflets. On circulatory arrest, a No. 28 aortic graft (Vascutec, Renfrewshire, Scotland) was anastomosed to the hemi-arch, with restoration of cardiopulmonary bypass through the graft. Coronary buttons were placed on the root replacement followed by anastamosis of the root to the graft. His postoperative course was uneventful, discharged on postoperative day 5.

Ascending aortic dilatation, when occurring in the sinus, causes associated annular dilatation with subsequent aortic insufficiency due to inappropriate coaptation of the leaflets. In this case, the leaflets remained relatively fixed while the sinus expanded and tore the weaker tissue below the commissural attachments, causing fenestrations in each of these attached areas. Therefore, not only was aortic insufficiency associated with inappropriate central coaptation, but also with peripheral fenestrations. Therefore, a valve-sparing repair was contraindicated.




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 Ann. Thorac. Surg.Home page
P. Urbanski
Commissural Fenestrations Are Not Contraindication for Aortic Valve and Root Repair
Ann. Thorac. Surg., December 1, 2009; 88(6): 2072 - 2073.
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Joseph E. Bavaria
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