Ann Thorac Surg 2009;88:2025-2027. doi:10.1016/j.athoracsur.2009.04.126
© 2009 The Society of Thoracic Surgeons
Case Reports
Geometric Reconstruction of the Sinus of Valsalva: Utilization of the Porcine Aortic Root
Joon Hwa Hong, MDa,
Nihan Kayalar, MDa,
Peter C. Spittell, MDb,
Soon J. Park, MDa,*
a Division of Cardiac Surgery, Mayo Clinic, Rochester, Minnesota
b Division of Cardiology, Mayo Clinic, Rochester, Minnesota
Accepted for publication April 21, 2009.
* Address correspondence to Dr Park, Mayo Clinic, 200 First St SW, Rochester, MN 55905 (Email: park.soon{at}mayo.edu).
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Abstract
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Surgical repair of ruptured sinus of Valsalva aneurysm can be challenging, although it has been reported that mortality and morbidity is low. Distortion of sinus of Valsalva geometry can cause aortic valve regurgitation immediately or progressively after surgery. Maintenance of the appropriate geometry of sinus of Valsalva after resection of the aneurysm is critical in preserving the native aortic valve and its competency. Successful reconstruction with various patch materials such as Dacron patches (DuPont, Wilmington, DE) or pericardial patches has been reported. Nevertheless, the size and shape of patches used had to be created impromptu by surgeons without reliable methodology of reproducing the precise shape of the naturally occurring sinus of Valsalva. Herein, we report a successful repair of sinus of Valsalva aneurysm by utilizing a porcine sinus of Valsalva from a commercially available Freestyle valve (Medtronic Inc, Minneapolis, MN). We believe that this is a previously unreported technique.
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Introduction
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Ruptured sinus of Valsalva aneurysm is a rare congenital abnormality that usually originates from the right coronary sinus and less frequently from the noncoronary and left coronary sinuses [1]. The rupture of the aneurysm most commonly occurs into the right ventricle followed by the right atrium causing significant left-to-right shunt [2]. Although surgical repair can be performed with a low risk, the development of aortic regurgitation is still a risk because repair of ruptured sinus of Valsalva aneurysm may cause sinus of Valsalva distortion, especially in patients with extensive aneurysms.
A 38-year-old man presented to a local emergency room with dyspnea for 10 days. He had no significant past medical history, except for a surgically corrected congenital cleft palate. He was noted to have an aneurysm of the sinus of Valsalva and was transferred to our hospital. With further evaluation, he was found to have a ruptured sinus of Valsalva aneurysm. The aneurysm involved the noncoronary sinus, and it ruptured resulting in the formation of a fistulous communication to the right atrium (Fig 1). The aortic valve was normal, except for trivial regurgitation. The patient underwent surgical repair.
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Fig 1. In the left side is the echocardiographic image showing the sinus of Valsalva aneurysm involving the noncoronary sinus and its communication to the right atrium. On the right side is the color Doppler image of the fistulous connection showing the shunting of blood from aorta to the right atrium.
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A median sternotomy incision was made. Cardiopulmonary bypass was established by placing an arterial cannula in the ascending aorta and venous cannulae in the cavae. The ascending aorta was cross-clamped, and the cardioplegia solution was delivered in both the antegrade and retrograde fashion. The aorta was incised to expose the sinus of Valsalva and aortic valve. The valve had three equal-sized leaflets, and they coapted well. The aneurysm involved the noncoronary sinus with a fibrous fistula tract into the right atrium just above the tricuspid valve (Figs 2A and 2B). The aneurysmal sinus was resected. The noncoronary cusp of the aortic valve was left intact, suspended at the aortic annulus and commissures. Reconstruction of the sinus preserving the precise inter-commissural distance was challenging. We measured the size of the sinotubular juncture by utilizing the Freestyle porcine valve sizer (Medtronic Inc, Minneapolis, MN). One third of the circumference should have corresponded to the inter-commissural distance of the intact sinus. The patient's sinotubular juncture corresponded to a 25-mm Freestyle valve sizer (Medtronic Inc). We resected a segment of porcine aorta, including the noncoronary cusp attachment at the annulus and commissures. Then, the porcine aortic cusp was removed as well (Fig 2C). This resembled the needed sinus of Valsalva of the patient. The patient's aortic root was reconstructed by sewing on the porcine sinus to the resected area of the sinus of Valsalva aneurysm (Fig 2D). The patient's aortic valve was not distorted on visual inspection after reconstruction. The fistula tract area of the tricuspid valve was plicated with pericardium reinforced 4-0 Prolene sutures (Ethicon Inc, Somerville, NJ). The right atrial incision was closed primarily. Intraoperative transesophageal echocardiogram demonstrated preserved aortic root geometry and well-functioning aortic valve with trace aortic insufficiency (Fig 3). The tricuspid valve also demonstrated no regurgitation. The patient is doing well with normally functioning native aortic valve on a follow-up transthoracic echocardiographic study performed 50 days after surgery.
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Fig 2. (A) The view of the sinus tract from right atrial site with right angle clamp within the atrial orifice of sinus tract. (B) Sinus tract opened with small arrow heads pointing commissural attachments and small black arrows pointing free edge of noncoronary cusp. In between two big black arrows is aortic annulus of noncoronary sinus of Valsalva. White arrows show opened fistula tract and its attachment to tricuspid valve. (C) Noncoronary sinus of porcine Freestyle graft, resected and trimmed for repair. (D) Reconstruction of noncoronary sinus with porcine aorta.
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Fig 3. Postoperative echocardiographic image demonstrating reconstructed sinus of Valsalva with good leaflet coaptation.
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Comment
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The main method of surgical repair of ruptured sinus of Valsalva aneurysm has been resection of the aneurysm and patch repair of the aortic root using patch materials such as Dacron (DuPont, Wilmington, DE) or pericardium [1–4]. Reconstructing the sinus of Valsalva with a patch, without distorting the aortic valve competency, is important [1, 2], but it has been challenging because the aortic root geometry is very complex to reproduce. We have successfully utilized a porcine aortic sinus as a patch material to reconstruct the aortic root after sinus of Valsalva aneurysm resection. This seems to be a simple and reproducible method of reconstructing the geometry of sinus of Valsalva and aortic competency.
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References
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- Van Son JAM, Danielson GK, Schaff HV, et al. Long term outcome of surgical repair of ruptured sinus of Valsalva aneurysm Circulation 1994;90(Suppl 2):20-29.
- Jung SH, Yun TJ, Im YM, et al. Ruptured sinus of Valsalva aneurysm: transaortic repair may cause sinus of Valsalva distortion and aortic regurgitation J Thorac Cardiovasc Surg 2008;135:1153-1158.[Abstract/Free Full Text]
- Feldman DN, Roman MJ. Aneurysms of the sinuses of Valsalva Cardiology 2006;106:73-81.[Medline]
- Azakie A, David TE, Peniston CM, Rao V, Williams WG. Ruptured sinus of Valsalva aneurysm: early recurrence and fate of the aortic valve Ann Thorac Surg 2000;70:1466-1471.[Abstract/Free Full Text]
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