Ruptured aneurysm of sinus of Valsalva into the right atrium with aortic valve perforation

A 58-year-old female was admitted to our hospital because of sudden dyspnea and general malaise. A continuous murmur was heard along the left sternal border. A chest X-ray showed cardiomegaly and pulmonary vascular marking. Doppler echocardiography confirmed the presence of an aneurysmatic mass, originating from the non-coronary sinus of Valsalva and extending to the right atrium, with a turbulent flow into the right atrium, aortic regurgitation (II/IV) and tricuspid regurgitation (III/IV). Ascending aortography demonstrated a communication between the aortic sinus and the right atrium. The pulmonary-to-systemic flow ratio was calculated to be 2.04. Oblique aortotomy and right atriotomy were performed. The aneurysm was resected and its origin was directly closed with horizontal mattress sutures through the aortic side and right atrial side. Perforation of a non-coronary cusp that caused aortic regurgitation was found following aortotomy and it was closed with an autologous pericardial patch. Tricuspid annuloplasty was performed using DeVega's technique. The postoperative course was uneventful, and she was discharged on the 10th postoperative day.     

Sinus of Valsalva dilatation after replacement of the ascending aorta and aortic valve

A 52-year-old woman, height, 149 cm; weight, 40 kg, was admitted because of anterior chest discomfort and palpitations. There was no family history of Marfan syndrome. She had undergone replacement of the ascending aorta and aortic valve 10 years prior for DeBakey II aortic dissection. Postoperative pathological examination of the resected aortic wall revealed cystic medionecrosis. Computed tomography(CT) 4 years after the surgery showed moderate enlargement of the preserved sinuses of Valsalva, and CT 10 years after the surgery showed enlargement of the sinus. She consented to a reoperation. The prostheses were explanted, and the aortic root was replaced with a composite graft. The right coronary artery ostium was completely closed, and no graftable portions of the distal right coronary artery were detected. Thus, the left coronary artery alone was reimplanted. The patient required extracorporeal membrane oxygenation for 10 days postoperatively, after which she recovered fully without complications. This case may indicate that the complete aortic root should be replaced during initial surgery of the ascending aorta or aortic valve in patients with potential risk of sinus of Valsalva dilatation.     

Long-term follow-up of supra-annular pulmonary autograft aortic root replacement in patients with bicuspid aortic valve

Objective: The performance of the Ross procedure in the case of geometric mismatch between pulmonary autograft and a bicuspid aortic root has not yet been fully evaluated. To prevent geometrically caused autograft dysfunction, a modification of the surgical technique is necessary. Methods: Between January 1996 and January 2007, 50 patients (33 male, 17 female; mean age 50+/-14 years; range 13-63 years) underwent replacement of a diseased bicuspid aortic valve (stenosis in 14 cases; insufficiency in 21; combined disease in 15) with a Ross procedure. The pulmonary autograft was inserted partially in supra-annular position to correct the geometric mismatch between the deeper base of the non-coronary sinus and the right/left coronary sinus. In 24 of these patients, additional tailoring of the non-coronary sinus was necessary. In eight patients the non-coronary sinus was covered with a glutaraldehyde treated autologous pericardial patch to prevent pseudoaneurysm formation. Patients were followed up 1, 2, 5 and 10 years postoperatively. Results: There were no early or late deaths. There were six reoperations. One patient was reoperated because of persistent severe aortic valve insufficiency 9 months postoperatively. Three patients were reoperated for formation of subannular pseudoaneurysm, 6, 9 and 30 months postoperatively. One patient was reoperated for closure of a paravalvular dehiscence. Another patient was reoperated 1 year postoperatively because of a severe pulmonary stenosis due to excessive calcification of the bioprosthesis. Echocardiographic follow-up of the remaining patients showed no evidence of residual or recurrent pulmonary autograft regurgitation or progression of aortic root dilatation. Conclusion: Autograft replacement of the bicuspid aortic valve is challenging, as the geometric mismatch has to be adjusted. Valve dysfunction is avoided by a supra-annular implantation technique, but pseudoaneurysm formation at the base of the non-coronary sinus is a worrying aspect. Patch reinforcement may solve this issue.     

Surgical experience with Aneurysm of the Sinus of Valsalva

During a three year period from July 1977 to July 1980, six cases of Aneurysm of the Sinus of Valsalva underwent surgical correction in our Institute. Three of them were males and three females. The constant symptoms were palpitations and fatigability and the constant signs were collapsing pulse and continuous murmur with thrill. In four cases the right coronary sinus had ruptured into the right ventricular outflow; in two patients, the non-coronary sinus was involved, one rupturing into the right atrium, the other one being unruptured. Four patients had associated aortic regurgitation and two had ventricular septal defect. All were corrected surgically; four patients with aortic regurgitation had aortic valve replacement; the ventricular septal defects were closed directly. One patient died on the operating table; one died at home suddenly, two months after surgery. The other four patients are doing well clinically, two to five years after surgery.     

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.     

A successful repair of infective endocarditis accompanied by a pseudoaneurysm of the left ventricle

The present paper reports a successful surgical treatment of a 47-year-old male with a pseudoaneurysm of the left ventricle. The patient has also been administered Penicilin G for 5 months to treat endocarditis. Cardiac catheterization showed severe aortic stenosis and a pseudoaneurysm of the left ventricle which was dilating in systole. The patient underwent patch closure of the pseudoaneurysm whose ostium was situated at the miral-aortic inter valvular fibrosa followed by aortic valve replacement and direct closure of a right Valsalva sinus aneurysm. His postoperative course was uneventful. The patient had no recurrence of endocarditis nor malfunction of the prosthetic valve for one year postsurgery. This is the first report in Japan of successful surgical treatment of a pseudoaneurysm of the left ventricle due to perforation of the miral-aortic intervalvular fibrosa after endocarditis.     

Case of primary aorto-jejunal fistula caused by gram-positive cocci

A 46 year-old man was transferred to our department with a pulsating abdominal mass and back pain. On arrival he suddenly developed hematemesis. CT suggested the presence of an infrarenal aortic aneurysm and the jejunum was filled with contrast medium. An emergency operation was done. We found an aorto-jejunal fistula at the branching point of the renal artery. We directly sutured the aortic wall laceration and the jejunum wall in two layers. Then we resected infrarenal pseudoaneurysm as completely as possible, with replacement by a Dacron Y-shaped prosthesis. Culture of the aortic wall showed gram-positive cocci, but the species could not be identified. Gram stain of the aortic wall also showed infection by gram-positive cocci. The patient is alive and well 3 months after surgery.     

Giant pseudoaneurysm of the right sinus of Valsalva

A pseudoaneurysm of the sinus of Valsalva is a very rare cardiac abnormality. We report a surgical case of the pseudoaneurysm of the right sinus of Valsalva in a 77-year- old woman. The histopathological examination of the resected aneurysmal wall revealed that it was a pseudoaneurysm without any specific inflammatory changes. Although we cannot identify the clear cause of the formation of the pseudoaneurysm, we believe it may have been a type of spontaneous rupture of the sinus of Valsalva.     

Giant sinus of valsalva aneurysm with severe aortic incompetence treated with a valve-sparing operation

Typically, a sinus of Valsalva aneurysm with severe aortic incompetence is repaired with patch closure and aortic valve replacement. Here, we describe a very rare case of a giant nonruptured right Valsalva aneurysm, combined with severe aortic incompetence, treated with a valve-sparing aortic root replacement. During surgery we noted that the lengths of the free margin of the cusps and annuli were not uniform. As a result, we placed the first layer of sutures for the Valsalva graft in the same ratio as the annuli. It is difficult to preserve the geometry of the aortic annulus and position the commissures in the graft. One surgical tip for valve-sparing aortic root replacement for a sinus of Valsalva aneurysm with severe aortic incompetence is to suture the commissures inside the graft in the same ratio as the length of the cusp free margins.     

Redo aortic root replacement for prosthetic valve detachment associated with recurrent aneurysm of sinus of valsalva due to aortitis syndrome

We report a case of 44-year-old male with aortitis syndrome who suffered a prosthetic aortic valve detachment and recurrent aneurysm of sinus of Valsalva 5 years after aortic valve replacement and patch closure of non-coronary sinus of Valsalva. Preoperative computed tomography (CT) and angiography revealed severe aortic regurgitation and complicated aneurysm formation of sinus of Valsalva due to prosthetic valve and prosthetic patch dehiscence. Aortic root replacement was performed successfully after induction of steroid therapy to control inflammation. His postoperative course has been uneventful for 18 months.     

Rapid expansion of mycotic aneurysm of left coronary sinus of Valsalva causing myocardial ischemia: report of a case

We described a 71-year-old female of aneurysm of the left sinus of Valsalva from mycotic origin. She underwent aortic valve replacement 11 years ago. Repeated CT scans showed rapidly growing aneurysm below the left coronary ostium. On sixth day after the admission, she suddenly developed myocardial ischemia complicated with ventricular fibrillation. The patient was treated with emergent aortic root replacement and she recovered. We recommend emergent surgical repair of mycotic saccular aneurysm of the left sinus of Valsalva because a delay of surgery could be fatal.     

Cardiac tamponade and death from intrapericardial rupture [corrected] of sinus of Valsalva aneurysm.

A 35-year-old woman presented with dyspnea and chest pain. She had a large aneurysm of the non-coronary sinus of Valsalva. Before her scheduled urgent surgery, the patient collapsed and died of cardiac tamponade secondary to intrapericardial rupture of the aneurysm. We would advocate urgent repair of this type of lesion to prevent such an outcome. We are aware of no other specific reports addressing extracardiac rupture of non-coronary cusp aneurysms [corrected].     

主动脉窦瘤的外科治疗

本文报告32例主动脉窦瘤的手术治疗，窦瘤发生及破入心腔部位不同，手术方法不尽相同，1例左冠窦窦瘤破入左房属罕风类型。本文着重探讨窦瘤破裂并发感染性心内膜炎（IE）的手术方法，作者认为瓣叶损害轻或右心IE行瓣膜修复术优于人互瓣膜置换术，1例并发IE，施行AVR后又发生人互心瓣膜IE患者猝死。     

Morphometrical and biomechanical analyses of a stentless bioprosthetic valve: an implication to avoid potential primary tissue failure

Objectives

Stentless bioprosthetic valves provide hemodynamic advantages over stented valves as well as excellent durability. However, some primary tissue failures in bioprostheses have been reported. This study was conducted to evaluate the morphometrical and biomechanical properties of the stentless Medtronic Freestyle? aortic root bioprosthesis, to identify any arising problem areas, and to speculate on a potential solution.

Methods

The three-dimensional heterogeneity of the stentless bioprosthesis wall was investigated using computed tomography. The ascending aorta and the right, left, and non-coronary sinuses of Valsalva were resected and examined by an indentation test to evaluate their biomechanical properties.

Results

The non-coronary sinus of Valsalva was significantly thinner than the right sinus of Valsalva (p?<?0.01). Young’s modulus, calculated as an indicator of elasticity, was significantly greater at the non-coronary sinus of Valsalva (430.7?±?374.2 kPa) than at either the left (190.6?±?70.6 kPa, p?<?0.01) or right sinuses of Valsalva (240.0?±?56.5 kPa, p?<?0.05).

Conclusions

Based on the morphometrical and biomechanical analyses of the stentless bioprosthesis, we demonstrated that there are differences in wall thickness and elasticity between each sinus of Valsalva. These differences suggest that the non-coronary sinus of Valsalva is the most vulnerable and at greater risk of tissue failure. The exclusion of the non-coronary sinus of Valsalva may be beneficial to mitigate the long-term risks of tissue failure in the stentless bioprosthesis.

     

Reoperation after aortic valvuloplasty for aortic regurgitation associated with ventricular septal defect

Five patients underwent reoperations because residual or recurrent aortic regurgitation occurred after aortic valvuloplasty for aortic regurgitation associated with ventricular septal defect. The mean age at reoperation was 22 years old, and the mean time interval between initial and second operation was 6 years, 10 months. The pathological findings of the aortic valves showed tears and perforation of repaired leaflets in four patients and a giant pseudoaneurysm of the Valsalva sinus in one. Aortic valvuloplasties were performed again in three patients, and aortic valves were replaced with prosthetic valves in two. Slight to moderate regurgitant murmurs are still audible in patients who underwent these valvuloplasties. Ventricular septal defects should be closed before aortic regurgitation develops. If it has developed, however, valvuloplasty should be considered as a first choice in young patients. For adult patients, aortic valve replacement is recommended.     

Simultaneous Aortic and Tricuspid Valve Endocarditis due to Complication of Sinus of Valsalva Rupture

We experienced a case of ruptured aneurysm of the sinus of Valsalva, and this resulted in simultaneous aortic and tricuspid valve endocarditis through a shunt. The echocardiography showed a ruptured sinus of Valsalva aneurysm to the right atrium with a shunt. The aortic non-coronary cusp was fibro-thickened with vegetation. Vegetations of the septal leaflet and the anterior leaflet of the tricuspid valve were also found. The blood culture grew Enterococcus garllinarum. We replaced both tricuspid and aortic valve with successful surgical result.     

Early valvular obliteration of cryopreserved aortic valve allograft

This report describes a 60-year-old male patient who developed early valvular obliteration of a cryopreserved aortic valve allograft with associated severe valvular leakage. The patient had previously undergone two operations for aortic valve insufficiency resulting from infective endocarditis, and prosthetic valve endocarditis: aortic valve replacement with a mechanical prosthesis was done 4 years ago, and two years later aortic root replacement with a cryopreserved allograft was performed. Perforation through the non-coronary cusp of the aortic allograft was found, and valve replacement was achieved using a mechanical prosthesis. The intraoperative findings, histological, immunological, and bacteriological studies of the resected cusps demonstrated negative for infection and rejection, therefore, the valvular perforation might have been caused by an injury or degeneration during management of the homologous graft. The patient showed neither aortic regurgitation on echocardiography nor recurrence of endocarditis 10 months after surgery.     

Coronary arterial compression caused by an aneurysm of the sinus of Valsalva with aortic prosthetic valve endocarditis

Myocardial ischemia caused by coronary arterial compression by an aneurysm of the sinus of Valsalva is a particularly unusual complication. We describe a patient with aortic prosthetic valve endocarditis complicated with an aneurysm of the sinus of Valsalva. An 82-year-old woman was admitted to our hospital with a high fever and chest discomfort. She had undergone aortic valve replacement 3?years earlier. Computed tomography showed an aneurysm originating from the left and right aortic sinus that was compressing the proximal left anterior descending coronary artery. The aortic root was successfully replaced and antibiotic treatment was continued for 6?weeks after surgery.     

Pseudoaneurysm of the mitral-aortic intervalvular fibrosa on a native aortic valve following infective endocarditis

Pseudoaneurysm of the mitral-aortic intervalvular fibrosa (MAIVF) rarely forms on native aortic valve after infective endocarditis (IE). It is often fatal because of its rapid progress, high rates of rupture and recurrence, and worsening effects on the systemic condition. Echocardiography, especially transesophageal echocardiography, plays an important role in the diagnosis and assessment of this condition. We experienced a rare case of a patient with an unfortunate course following native aortic valve IE. After the patient had undergone surgical evacuation of a blood clot due to the rupturing of an embolomycotic cerebral aneurysm, a pseudoaneurysm of the MAIVF was found. Aortic valve replacement and pseudoaneurysm repair were performed 3 months after the neurosurgery. Echocardiographic still images were obtained during these two operations.     

Commissural detachment and Valsalva sinus dilatation after implantation of Prima Plus stentless valve with full root technique

The stentless aortic bioprosthesis has been used because of its excellent hemodynamics and few valve-related complications. We report a case of redo aortic root replacement for severe aortic regurgitation and dilatation of the Valsalva sinus 7 years after the implantation of a Prima Plus aortic root bioprosthesis (Edwards LifeScience, Irvine, CA, USA) using a full root technique. Intraoperative findings showed the complete detachment of the commissure between the left and non-coronary cusps, and Valsalva sinus dilatation of the porcine aortic root bioprosthesis. Redo aortic root replacement with a 23-mm porcine bioprosthesis and 28-mm straight graft was performed. There were no findings of intimal tear, suture dehiscence, degeneration, and perforation of the bioprosthesis. Such complications associated with the Edwards Prima Plus aortic root bioprosthesis were rarely reported. Commissural detachment of a porcine stentless aortic bioprosthesis can occur; thus, careful follow-up involving echocardiography and computed tomography is necessary.