Unruptured sinus of Valsalva aneurysm involving all three sinuses

In contrast to generalized aneurysmal dilatation of the aortic root, discrete sinus of Valsalva aneurysm is an uncommon condition most often affecting the right coronary sinus. We recently treated a patient without the known connective tissue disorder having discrete aneurysms of all three sinuses.     

Ruptured aneurysms of the sinus of Valsalva

From 1964 to 1984, 10 male and 5 female patients with ruptured aneurysms of the sinus of Valsalva (ASVs) underwent surgical correction. These procedures constituted 0.23% of the 6,350 surgical procedures that used cardiopulmonary bypass during this period. Five patients had an inflammatory condition (bacterial endocarditis, 4; syphilis, 1), and 1 had an ASV relapse 5 years after her first operation. Coexistent lesions included aortic valve regurgitation in 5 patients, ventricular septal defect in 3 (1 of whom had mitral insufficiency), patent foramen ovale in 2, and atrial septal defect in 1. Ninety-three percent were symptomatic (sudden onset of symptoms, 5 patients; gradual onset, 9 patients), commonly with shortness of breath, fatigability, chest pain, and tachycardia. The following connections occurred: noncoronary sinus to right atrium (RA) (5 patients); right coronary sinus (RCS) to RA (5 patients); and RCS to right ventricle (5 patients). There were no early or late postoperative deaths. One patient underwent reoperation after an ASV relapse. The mean follow-up period (+/- standard deviation) was 7.9 years (range, 10 months to 20.1 years). Eighty percent of the patients were found to be in New York Heart Association class I, and 20% were in class II. Apart from ASV relapse, late complications are determined by prosthetic valve dysfunction or evidence of valve disease. Early surgical intervention is justified in patients with ruptured ASV.     

Surgical treatment and long-term results of aneurysms of Valsalva sinus in 24 cases

Twenty-four patients with aneurysm of Valsalva sinus were surgically repaired over a 23 year period (1965-1988). These patients were ranged 2 to 54 years of age and eleven of them were male. Rupture of aneurysm of Valsalva sinus was combined with aneurysm in 20 cases, ventricular septal defect in 12 cases and aortic regurgitation in 6 cases. At present, our routine operative procedure for ruptured aneurysm is direct closure of the defect with patch closure of aneurysm after resection of the aneurysm, but when the diameter of aneurysm is smaller than 7 mm, direct closure of the defect of the aneurysm was used. Only one patient after patch closure of ruptured sinus of Valsalva (Konno type I) required reoperation for penetration into left ventricle. This case might be avoided if patch was sutured to annulus of aortic valve. There were two operative death and one late death. The former died of cerebral infarction and low output syndrome, the latter died of sepsis. The mean follow-up period (+/- standard deviation) was 8.2 +/- 6.0 years. All patients that were followed were thirteen and found to be in New York Heart Association class I.     

Approach to sinus of Valsalva aneurysms: a review of 53 cases.

OBJECTIVE: The reported experience with sinus of Valsalva aneurysms (SVAs) is limited. Our approach to this subset of patients and an algorithm-dependent classification are presented. METHODS: Between 1985 and 2000, 53 patients (mean age: 24+/-12; range 4--60) underwent repair for ruptured (64%) or non-ruptured (36%) SVA. Associated lesions were present in 21 patients; VSD in 18, moderate to severe aortic insufficiency in five, aortic stenosis in four (two subaortic membrane and one bicuspid valve), PDA in two, mitral insufficiency in one, tetralogy of Fallot in one and endocarditis in one. Operative procedures included simple or Teflon pledgetted direct suturing (31 cases; 58%), patch repair (21 cases; 40%), and stentless porcine bioprosthetic aortic root replacement in a case with extensive involvement and aortic root distortion (2%). Concomitant procedures were VSD repair in 18 patients, aortic valve replacement in four, aortic valve resuspension in three, subaortic membrane resection in two, PDA ligation in two, mitral annuloplasty in one and total correction in one. RESULTS: Early mortality was 1.9%. A permanent pacemaker was inserted in one patient due to complete heart block. The survivors were followed up for 8.2+/-5 years (range: 21 days to 15 years). There were three reoperations due to suture dehiscence; patch repair was undertaken in these patients with no further unfavorable consequences. All patients were in NYHA Class I or II as of their last follow-up. CONCLUSIONS: Repair of SVA can be performed with an acceptably low operative risk and a good symptom-free long-term outcome expectation. Echocardiography provides all the necessary details for diagnosis. Dual exposure/patch repair strategy is advocated in the ruptured cases.     

Ruptured aneurysms of the sinus of Valsalva.

From 1969 to 1989, 15 patients with an aneurysm of the sinus of Valsalva underwent operative correction. This represents 0.23% of 6515 cardiac operations with cardiopulmonary bypass during that time. There were 8 males and 7 females ranging in age from 15 to 54 years (mean 35.8 years). Symptoms of congestive heart failure, fatigue and palpitation were common. All patients underwent cardiac catheterization including aortography. Associated lesions included aortic valve regurgitation in 6 patients and a ventricular septal defect in 3 patients. The following connections occurred: right coronary sinus to right ventricle (8 patients), right coronary sinus to both right atrium and right ventricle (1 patient), and noncoronary sinus to right atrium (6 patients). The aneurysm was repaired via aortotomy or through the chamber into which it emptied. The aortic valve was replaced in 2 patients. There were no early or late postoperative deaths. Fourteen patients were in NYHA functional class I at late follow-up (range 0.5 to 20.5 years, mean 8.7 years). There have been no recurrences. Our experience supports the concept that early surgical intervention in patients with ruptured aneurysms of the sinus of Valsalva is justified.     

Isolated extracardiac unruptured sinus of Valsalva aneurysms.

Reports concerning unruptured, isolated aneurysms of one sinus of Valsalva are rare. These aneurysms usually protrude inside the heart and are very rarely extracardiac. We report 4 cases of isolated, unruptured extracardiac aneurysms of the noncoronary sinus of Valsalva. Clinical symptoms were nonspecific. Operation was performed by patch reconstruction of the dilated aortic sinus without replacement of the ascending aorta. Microscopic examination of the diseased aortic wall revealed absence of medial elastic fibers. Late follow-up in all 4 cases revealed a normal ascending aorta with no dilatation of the aortic root and no aortic regurgitation.     

Unruptured aneurysm of the noncoronary sinus of Valsalva protruded into the left atrium; report of a case

A successful operative treatment of an unruptured aneurysm of the noncoronary sinus of Valsalva protruded into the left atrium is reported. A 64-year-old female was unexpectedly found an aneurysm of the sinus of Valsalva during the examination of bradycardia. Cardiac angiography and two dimensional echocardiography demonstrated the unruptured aneurysm of the noncoronary sinus of Valsalva of 35 mm in diameter, which protruded into the left atrium. She underwent the surgery. The aneurysm was excised and the aortic root defect was closed with a Woven dacron patch. The postoperative course was uneventful. Pathologic examination revealed the atherosclerotic change of the aorta. As far as we know, this patient is the first reported case of the unruptured aneurysm of the noncoronary sinus of Valsalva protruded into the left atrium in this country.     

Ruptured aneurysms of sinus of Valsalva with bicuspid aortic valve--a case report of an aged patient (72 years old)

A 72-year-old man with ruptured aneurysms of the sinus of Valsalva and a bicuspid aortic valve was operated. Ruptured aneurysms were found in the noncoronary sinus region, and they were opened to the commissure between the anterior cusp and septal cusp of the tricuspid valve. The tissue around the aneurysm was very weak, so closure of the ruptured hole was carried out from the inside of both aorta and right atrium. Ruptured aneurysm of Valsalva is very rare in a aged patient. In this case, it is considered that the bicuspid aortic valve associated with malformations of the aortic cusp caused a weakness of the sinus wall, and this region gradually became aneurysmal.     

Unruptured aneurysm of the sinus of Valsalva associated with right ventricular outflow tract stenosis; report of a case

A 51-year-old female was referred to our hospital for heart murmur and was diagnosed with right ventricular outflow stenosis by echocardiography. Six years later, follow-up echocardiogram revealed that the stenosis was caused by an aneurysm of the sinus of Valsalva (2 cm in diameter) originated from the right coronary sinus. Resection and patch closure of the aneurysm were carried out under complete cardiopulmonary bypass. The aneurysm was not associated with ventricular septal defect and was categorized as Sakakibara-Konno type I. Postoperative state was uneventful. Systolic murmur disappeared and pressure difference in the right ventricular outflow was normalized.     

Surgical treatment of ruptured aneurysms of the sinus of Valsalva

Aneurysms of the sinus of Valsalva are usually congenital in origin. When they rupture, it is generally into the right atrium or the right ventricle. Signs of a left-to-right shunt, aortic runoff, and cardiac decompensation are the cardinal features. Early diagnosis and surgical correction result in cure. We report our experience with 28 patients. In all patients, we used a combined aortocameral approach, and we recommend a sandwich patch for the repair. Aortic valve replacement is needed only in patients with severe degenerative changes. The overall operative mortality was 21.4%, but in the last 10 years, mortality was only 11.7%. The causes of operative and late mortality are discussed.     

Ruptured aneurysms of the sinus of Valsalva in Oriental patients

Between 1964 and 1987, a total of 57 cases of ruptured aneurysm of the sinus of Valsalva underwent surgical correction at the National Taiwan University Hospital. This represents 0.96% of all cardiac operations. The origin of ruptured aneurysm of the sinus of Valsalva was the right coronary sinus in 46, the noncoronary sinus in nine, and the left coronary sinus in two. The aneurysms ruptured into the right ventricle in 44, into the right atrium in 11, into the left ventricle in one, and into both the right ventricle and right atrium in one. Associated congenital cardiac anomalies included ventricular septal defect in 30 patients, aortic regurgitation in 20, and infundibular pulmonic stenosis and coarctation of the aorta in one each. Operative death occurred in two patients (3.5%) and one patient had a successful reoperation. The remainder did well following surgery. To compare the differences between Oriental and Western countries in ruptured aneurysm of the sinus of Valsalva, 361 cases (195 Oriental patients versus 166 Western) were collected from the literature. Analyses of these cases revealed that ruptured aneurysm of the sinus of Valsalva in Oriental patients compared with Western series is characterized by a higher incidence (5 times), more aneurysms originating from the right coronary sinus (87.9% versus 63.6%), more aneurysm rupturing into the right ventricle (84.2% versus 56.6%), a higher incidence of association with ventricular septal defect (mainly supracristal) (59.0% versus 34.6%), less incidence of association with other congenital cardiac abnormalities (4.1% versus 21.5%), very few instances of rupturing into cardiac chambers other than the right ventricle and right atrium, and less incidence of occurrence in the extremities of ages (the youngest was 7 years in Oriental patients versus 11 months in the Western series). In other words, ruptured aneurysm of the sinus of Valsalva in Oriental patients is more or less a simple and uniform disease entity in contrast to the more diverse and protean pathologic profiles encountered in Western series. However, both Oriental patient and Western patient series have similar incidences of combination with aortic regurgitation (24.6% versus 20.0%), with 40.4% of Oriental patients and 60.6% of Western patients presenting with intact ventricular septum. Therefore the pathogenetic mechanisms of ruptured aneurysm of the sinus of Valsalva may at the same time contribute to the development of aortic regurgitation.     

Surgical treatment of aneurysms of the sinus of Valsalva.

From 1962 to 1976, 15 patients with aneurysms of the sinus of Valsalva underwent operative correction. All patients survived operation. Follow-up has been carried out for as long as fifteen years (median, six years) after operation. There have been no late deaths and no recurrences. Aortic insufficiency, present in 2 patients before and in 2 after operation, remained well compensated and required no further aortic valve procedure. A double approach, that is, through both the aorta and the involved cardiac chamber, is recommended for sufficient correction.     

Unruptured aneurysm of the right coronary sinus of Valsalva with type B aortic dissection

A seventy-two year-old man, who complained of severe back pain, was referred to our hospital. Digital subtraction angiogram (DSA) delineated an extracardiac unruptured aneurysm of the right coronary sinus of Valsalva and acute type B aortic dissection. Patch plasty of the right coronary sinus with reimplantation of the right coronary artery using a Dacron graft was performed. Postoperative DSA confirmed successful reconstruction of the aortic root and the patent right coronary artery.     

Unruptured intracranial aneurysms associated with vascular disorder of the vertebro-basilar system: report of five cases

Among fifty-two angiographically examined patients of vertebro-basilar disorder, incidental intracranial aneurysms were found in five cases. These were four males and a female, ages ranging from 42-67 year old. Vertebro-basilar disorders were ischemic origin in three cases and hemorrhage in two cases. Locations of incidental aneurysms were the internal carotid artery, middle cerebral artery, anterior communicating artery and basilar artery. They were multiple in three cases. They were operated on radically, except one case whose status seemed to be untolerable to the operation. Intervals between strokes and operations were 51-81 days. In spite of successful operation, mild to moderate disturbances of consciousness appeared in three cases. In two cases they were subsided in a week, but in one case it persisted for two months. Fortunately, final results in all operative cases were good. These transient deterioration of consciousness level might probably be ascribed to vertebro-basilar insufficiency once subsided but resumed due to the operative affections. Through a small experience of four cases, three points would be discussed to prevent such hazards. 1) Extreme systemic hypotension as well as hypertension should be avoided during operation. 2) GOF might be an anesthesia of choice in such cases. 3) Operation should be favorably waited for more than six months after the ictus.