主动脉窦瘤破裂的外科治疗及远期疗效

目的 总结主动脉窦瘤破裂的临床特点及外科疗效,讨论对合并感染性心内膜炎及主动脉瓣关闭不全患者的处理.方法 回顾性分析1997年9月至2007年9月43例主动脉窦瘤破裂患者的临床资料.其中男性32例,女性11例;年龄11～50岁,平均年龄(29.0±11.5)岁.破口源于右冠状动脉窦34例,无冠状动脉窦9例.破入有心室30例,右心房8例,右心室及右心房3例,破人室间隔2例.合并室间隔缺损26例,主动脉瓣关闭不全15例,感染性心内膜炎8例,三尖瓣反流6例,房间隔缺损4例,二尖瓣反流2例,动脉导管未闭2例,肺动脉赘牛物1例.全部患者于心肺转流下行窦瘤修补及合并畸形矫治术.结果 无围手术期死亡.并发症5例,包括急性左心功能衰竭3例,Ⅲ度房室传导阻滞2例.随访6～120个月,平均(68.0±17.7)个月;2例分别于术后第6、8年行主动脉瓣置换术,2例进展为Ⅱ级主动脉瓣父闭小全.结论 主动脉窦瘤破裂外科治疗可获得满意效果.对合并主动脉瓣关闭小全及感染性心内膜炎的患者应早期手术,积极防治术后并发症并长期随访.     

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.     

A case report of surgical repair of ruptured aneurysm of sinus valsalva in aged (84 years old)]

An 84-year-old man with ruptured aneurysm of Valsalva sinus was operated. Diagnosis was made by two dimensional echocardiography, cardiac catheterization, and cardiac angiography. A aneurysm was found at the right-coronary sinus region, and ruptured into the right ventricle. The ruptured aneurysm of sinus Valsalva was repaired with direct closure and Woven patch from inside the right ventricle through the pulmonary valve. This case was defined as congenital because there was no sign of inflammatory or atherosclerotic changes in the aorta, aortic valve and aneurysm. The ruptured aneurysm of sinus Valsalva is very rare in aged patients. As far as we know, this patient is one of the oldest cases who underwent successful surgical repair in this country.     

Ruptured congenital sinus of valsalva aneurysms

BACKGROUND AND AIM OF THE STUDY: Rupture of the sinus of Valsalva is rare, and there is a higher incidence of such rupture in Oriental countries than elsewhere. The objective of this study is to present the pathologic features and the clinical outcome after surgery in such patients. METHODS: Between 1980 and 2001, a total of 17 patients (15 males and 2 females) with ruptured aneurysm of sinus of Valsalva underwent surgical intervention at the Tri-Service General Hospital, Taiwan. Their age ranged from 22 to 59 years with a mean of 33.5 years. These surgical operations made up 0.51% of the total cardiac operations (3305) performed during this period. The medical records were retrospectively reviewed. RESULTS: The origin of the ruptured aneurysm of the sinus of Valsalva was the right coronary sinus in 12 patients, the noncoronary sinus in 4, and the left coronary sinus in one patient. The aneurysms ruptured into the right ventricle in 12 patients, into the right atrium in 3 patients, and into the left ventricle in 2 patients. Associated cardiac anomalies were aortic regurgitation in eight patients, ventricular septal defect in seven, and coronary artery fistula in one patient. There was no early postoperative death and one patient underwent a second operation after aneurysm of the sinus of Valsalva (ASV) relapse. CONCLUSIONS: The operation for a ruptured aneurysm of sinus of Valsalva carries a low operative risk and results in excellent long-term survival after surgical treatment.     

A case report of ruptured aneurysm of the sinus Valsalva resulted in tricuspid valve endocarditis]

A case of a 42-year-old man with ruptured aneurysm of the sinus Valsalva resulted in tricuspid valve endocarditis was reported. The aneurysm originating from the right sinus Valsalva ruptured into the right atrium, which caused tricuspid valve endocarditis. The aneurysm was closed through right atrial approach. A part of the septal leaflet of tricuspid valve including vegetation was resected and repaired.     

A case of ruptured aneurysm of Valsalva sinus into right atrium with peculiar findings on aortography

A 24-year-old man with ruptured aneurysm of sinus of Valsalva into the right atrium originating from the noncoronary sinus is presented. On aortography through the ascending aorta the right atrium in systolic phase and the right ventricle in diastolic phase were opacified. We considered ruptured aneurysm like a streamer (wind sock) entered into the right ventricle in diastolic phase and into the right atrium in systolic phase. Post-aneurysmectomy course was uneventful, and radiographic examination revealed complete repair of the aneurysm.     

Adult aortic coarctation discovered incidentally after the rupture of sinus of Valsalva aneurysm: combined surgical and interventional approach

Combination of ruptured sinus of Valsalva aneurysm (SVA), and a coexisting asymptomatic adult aortic isthmic coarctation is extremely rare. The timing and sequence of surgical and/or interventional repair of these two pathologies are controversial. We present a case of a 37-year-old male who was admitted to our department because of severe acute congestive heart failure and signs of ruptured aneurysm of the SV into the right ventricle. Transthoracic and transoesophageal echocardiography confirmed the communication between an important right coronary SVA and right ventricle, bicuspid aortic valve, mild aortic regurgitation, and revealed severe aortic coarctation. Because of the severe dilation of right sinus of Valsalva a surgical repair of the ruptured aneurysm was performed. Aortic coarctation was treated four weeks later by a percutaneous stent-graft implantation. This case report supports the concept that hybrid approach is feasible in patients with ruptured SVA and aortic coarctation in adulthood.     

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.     

主动脉窦瘤破裂12例外科治疗

本文报道12侧主动脉窦瘤破裂的外科治疗体会。表组合并室间隔缺损5例,主动脉关闭不全5例,细菌性心内膜炎2例。11例为右冠窦瘤破入右室或右房,1例为左和无冠窦瘤破入左室流出道。全组病例行直接或补片修补窦瘤,并补片修补室间隔缺损,对主动脉瓣关闭不全采取成形2例,2例主动脉瓣置换术。手术死亡1例。文中对其诊断、手术时机、心肌保护、手术方法进行了讨论。     

两种封堵器治疗主动脉窦瘤破裂的疗效及安全性

目的探讨应用动脉导管未闭(PDA)封堵器和室间隔缺损(VSD)封堵器治疗主动脉窦瘤破裂的疗效和安全性。方法对19例主动脉窦瘤破裂患者,按所用封堵器分为PDA封堵器组和VSD封堵器组,根据升主动脉造影结果,选择比破口直径大2~5mm的PDA封堵器或VSD封堵器进行经导管介入封堵。术后随访观察临床症状、心电图、残余分流、封堵器形态、有无瓣膜反流等情况。结果两组患者年龄、发病时间和术前TTE所示破口直径、主动脉造影示破口直径差异均无统计学意义(P均0.05)。19例均经升主动脉造影确诊为主动脉窦瘤破裂,其中15例右冠状动脉窦瘤破裂入右心室,3例为右冠状动脉窦瘤破裂入右心房,1例无冠状动脉窦瘤破裂入右心室;共使用PDA封堵器10枚,VSD封堵器11枚,成功率分别为60.00%(6/10)和90.91%(10/11)。术后随访6个月~6年,未发生血栓事件,无瓣膜反流,无心律失常、感染性心内膜炎、心力哀竭及死亡。结论经导管介入治疗主动脉窦瘤破裂安全有效;应用VSD封堵器较PDA封堵器有一定优势。     

Surgical repair of ruptured aortic sinus of Valsalva aneurysm

Surgical repair of ruptured aortic sinus of Valsalva aneurysm was performed on six patients. The NYHA functional class was I in one case, II in three and III in two cases. All aneurysms had ruptured into the right atrium. Three originated from the right, and three from the non-coronary aortic sinus of Valsalva. The preoperative shunt was 55-200% (mean 118%) of the peripheral cardiac output. At aneurysmal repair, closure of secundum-type atrial septal defect was performed in one case and insertion of a St Jude Medical aortic valve in another. There were no perioperative deaths. Five patients were asymptomatic in the follow-up period (5 months-17 years). One patient died of cardiomyopathy 11 years postoperatively. The long-term results after surgical repair of ruptured aortic sinus of Valsalva aneurysm thus were good, and early operation is recommended in order to avoid congestive heart failure.     

Ruptured congenital aneurysm of the sinus of Valsalva. Clinical manifestations, diagnosis, and results of surgical corrections

An experience with the management of 27 cases of ruptured sinus of Valsalva aneurysm is reported from the Bakulev Institute of Cardiovascular Surgery, Moscow. The right coronary sinus was involved in 23 cases and the noncoronary sinus in four cases. Rupture into the right ventricle occurred in 19 cases, whereas eight ruptures entered the right atrium. Twelve patients had a ventricular defect, and 10 patients had aortic regurgitation, requiring leaflet suspension in five patients or valve replacement in five patients. The surgical management and results are presented.     

Ruptured congenital aneurysm of the sinus of valsalva in the aged

Ruptured aneurysm of the sinus of Valsalva is a rare cardiac lesion. A ruptured aneurysm of the sinus of Valsalva in the right ventricle of a 64-year-old man was successfully repaired. The patient was admitted to the hospital with high fever and chest oppression. Diagnosis was made by two dimensional echocardiography, cardiac catheterization, and cardiac angiography. An aortotomy, main pulmonary arteriotomy, and right ventriculotomy were performed. There was no VSD, and the aneurysm originated from the right coronary sinus, rupturing into the right ventricle inlet portion. The ruptured aneurysm of the sinus of Valsalva was closed with a Dacron patch from inside the aorta. He is doing well after surgery. There was no heart murmur. CTR decreased and pulmonary blood flow fell to a normal value. As far as we know, this patient is the second oldest patient in Japan with surgical repair.     

外科治疗主动脉窦瘤70例的远期疗效分析

目的　总结 70例主动脉窦瘤的外科治疗经验。方法　 1988年 9月～ 2 0 0 3年 10月收治主动脉窦瘤患者 70例 ,占同期所有体外循环手术病例的 1 4 % ( 70 /496 0 ) ,其中男性 4 5例 ,女性 2 5例 ,年龄 3～ 6 9岁 [平均 ( 2 9± 15 )岁 ]。窦瘤突入右心室 4 6例、右心房 2 3例、左心室 1例。起源于右冠状动脉窦者 6 1例 ( 87% ) ,无冠状动脉窦者 9例 ( 13% )。最常见的合并畸形为室间隔缺损 ( 34例 )和主动脉瓣关闭不全 ( 2 1例 )。手术采用单一右心房、右心室或主动脉切口或主动脉切口与右心房、右心室联合切口 ,直接缝合 ( 4 3例 )和补片修补 ( 2 7例 )闭合主动脉窦部缺损 ,术中行主动脉瓣置换术6例。结果　无术后早期死亡。 1997年以前术后住院天数为 8～ 33d[平均 ( 14 3± 6 4 )d],1997年以后术后住院天数为 6～ 15d[平均 ( 9 1± 2 6 )d]。术后并发切口感染 4例、出血 3例、气胸 1例、心律失常 4例和室间隔缺损修补术后残余漏 1例。随访 5 3例 ( 76 % ) ,随访时间 2个月～ 13年 [平均( 6 6± 3 8)年 ],除 1例术后 7年死于主动脉夹层破裂外 ,全部存活 ,心功能为NYHA分级Ⅰ～Ⅲ级 ;合并主动脉瓣关闭不全者 ( 15例 )较未合并主动脉瓣关闭不全者 ( 38例 )心功能差 ( χ2 =8 30 ,P <0 0 1) ,主动脉窦     

Interatrial rupture of a non-coronary sinus of Valsalva aneurysm: a rare presentation of a rare disorder

A 65-year-old male was referred to our team after the incidental finding of a large non-coronary sinus of Valsalva aneurysm on computed tomography (CT)-scan of the thorax. Further imaging with transesophageal echocardiography (TOE) excluded intracardiac shunting. Unusually, the aneurysm had ruptured into the interatrial septum and was seen to be compressing both atria. At operative intervention, a 20 mm defect which had replaced the non-coronary sinus was repaired using a patch graft. An aneurysm of an aortic sinus is a rare disorder, and a rupture of a non-coronary sinus typically results in the formation of a fistulous tract in the right atrium. These images highlight an unusual case of a non-coronary sinus of Valsalva aneurysm which ruptured into the interatrial septum (IAS), and demonstrate the benefit of multi-modality cardiac imaging in guiding surgical repair.     

Surgical repair and long-term results in ruptured sinus of Valsalva aneurysm

Thirty-one patients with a ruptured sinus of Valsalva aneurysm (SVA) were operated on between January, 1961, and December, 1987. Twenty-five patients (81%) were in New York Heart Association (NYHA) Functional Class III or IV. Coexistent cardiac anomalies included a ventricular septal defect (VSD) in 16 patients (52%) and aortic valve regurgitation in 12 patients (39%). The ruptured SVA originated from the right coronary sinus in 29 patients (94%) and the noncoronary sinus in 2 patients (6%), and drained into the right ventricle in 30 patients (97%). In 6 patients treated recently, we used patches to repair the ruptured SVA and VSD through a double approach, thereby avoiding a ventriculotomy. This method resulted in no recurrent rupture or residual VSD postoperatively. There was one operative death (3%) and 4 late deaths (13%). Of the 26 surviving patients, 22 (85%) were in NYHA Class I at follow-up ranging from 6 months to 26.7 years (mean, 11.1 years). Actuarial survival at 25 years is 85.6 +/- 7.4% (mean +/- standard deviation). Repair of ruptured SVA with a patch through a double approach provides an excellent operative procedure and offers a long-term outcome.     

Aneurysm of coronary sinus of Valsalva can rupture anytime!

An aneurysm of the sinus of Valsalva ruptures in about 35% of all cases and only leads to acute symptoms in 25% of all patients. This paper illustrates a case of a patient who was scheduled for an elective operation due to an aneurysm of the right coronary sinus of Valsalva, which ruptured and led to the necessity of an emergency surgery.     

Aneurysm of sinus of Valsalva

Aneurysm of sinus of Valsalva is a rare cardiac abnormality with congenital origin in most of the cases. If it is located in the right coronary sinus, it usually ruptures into a right heart chamber and frequently a ventricular septal defect (VSD) coexists with this condition. Early diagnosis and immediate surgical treatment can save the patient's life in most cases. All the 3 cases reported in this series had aneurysm of right sinus of Valsalva with associated VSD and mild degree of aortic regurgitation (AR). Two of the cases ruptured aneurysm into the right ventricle. Trans-esophageal echocardiography was used to confirm the diagnosis and all three showed good results with surgery.     

室上嵴上室间隔缺损的外科治疗

本文报道５６例室上嵴上室间隔缺损的外科治疗。男３４例，女２２例，年龄３～３９岁。１９例合并主动脉瓣叶脱垂、主动脉瓣关闭不全或佛氏窦瘤破裂。经右房切口修补室缺２例，右室漏斗切口４７例，肺动脉切９７例。直接修补缺损２６例，补片修补３０例。主动脉瓣成形术１例，主动脉瓣置换术５例。５４例全愈出院，死亡２例。作者认为室上嵴上空间隔缺损应尽早手术，以免并发主动脉瓣损害和佛氏窦瘤破裂；中度主动脉瓣关闭不全可行主动脉瓣成形术，采用肺动脉切口优于右室漏斗部切口。     

超声心动图结合心血管造影诊断主动脉-左心室通道及误诊分析

目的探讨超声心动图结合心血管造影对主动脉-左室通道的诊断价值及误诊分析。方法对6例经手术证实为主动脉-左心室通道患者的超声心动图及心血管造影结果进行回顾性分析。结果 5例超声心动图做出正确诊断,误诊1例。5例心血管造影做出正确诊断,误诊1例。结论心血管造影结合超声心动图对主动脉-左室通道的检出具有重要意义,且二者结合可减少误诊。