Case Study
Direct closure of an asymptomatic right coronary sinus of Valsalva aneurysm
Asian Cardiovascular & Thoracic Annals 2014, Vol. 22(5) 601–603 ß The Author(s) 2013 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav DOI: 10.1177/0218492313479952 aan.sagepub.com
Giulio Tessitore1, Francesco Alamanni1, Sarah Ghulam Ali2 and Marco Zanobini1
Abstract A 52-year-old man was referred for evaluation of palpitation. Transthoracic echocardiography revealed an extracardiac aneurysm of the right coronary sinus of Valsalva, and normal anatomy of the aortic valve with no regurgitation. Threedimensional computed tomography confirmed the aneurysm with a diameter of 21 13.7 mm arising from the right coronary sinus of Valsalva under the right coronary artery. Surgical repair was performed without changing the normal anatomy of the aortic valve, preserving the right coronary ostium. Intraoperative and postoperative echocardiography showed complete closure of the aneurysm with normal functioning of the aortic valve.
Keywords Aortic aneurysm, sinus of valsalva, echocardiography
Introduction Sinus of Valsalva aneurysm (SVA) is a rare cardiac anomaly that may be acquired or congenital.1 SVA is caused by separation of the aortic media of the sinus from the media adjacent to the hinge line of the aortic valve cusp.2 Acquired aneurysms are caused by conditions affecting the aortic wall, such as infections (syphilis, bacterial endocarditis, or tuberculosis), trauma, or connective tissue disorders. Unruptured SVA is generally asymptomatic and its diagnosis is usually incidental. We describe an asymptomatic unruptured SVA that was treated by direct interrupted pledgeted suturing.
Case report A 52-year-old man was referred to our hospital for evaluation of palpitation, with a history of Becker muscular dystrophy, hypertension, and dyslipidemia. Transthoracic echocardiography revealed an extracardiac aneurysm of the right coronary sinus of Valsalva with normal anatomy of the aortic valve and no aortic regurgitation (Figure 1). Three-dimensional computed tomography confirmed the presence of the aneurysm measuring 21 13.7 mm, arising from the right coronary sinus of Valsalva under the right coronary artery (Figure 2). Coronary angiography also showed the
presence of the aneurysm and critical disease of the intermediate branch of the main coronary artery. A median sternotomy was performed. Cardiopulmonary bypass was instituted between the ascending aorta and right atrium. After cardiac arrest with cold blood cardioplegia, the ascending aorta was transected at the level of the sinotubular junction. The aortic wall of the aneurysm was thin, but the other sinuses had normal thickness. Surgical repair of the valve annulus and right coronary ostium was performed inside the sinus of Valsalva, using 4 interrupted pledgeted sutures, preserving the normal anatomy of the aortic valve and right coronary ostium. The intermediate branch of the main coronary artery was perfused through the left internal thoracic artery. Intraoperative and postoperative echocardiography showed complete closure of the aneurysm with 1 Department of Cardiovascular Surgery, IRCCS Centro Cardiologico Fondazione Monzino, Milan, Italy 2 Department of Cardiovascular Imaging, IRCCS Centro Cardiologico Fondazione Monzino, Milan, Italy
Corresponding author: Giulio Tessitore, Department of Cardiovascular Surgery, Istituto Clinico Citta` Di Alessandria, Via Bruno Buozzi, Alessandria, Italy. Email: [email protected]
Downloaded from aan.sagepub.com at Virginia Tech on March 14, 2015
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Asian Cardiovascular & Thoracic Annals 22(5)
Figure 1. Preoperative transesophageal echocardiography showing the aneurysm of the sinus of Valsalva at the level of the right coronary sinus.
Figure 3. Postoperative echocardiography showing complete closure of the aneurysm.
structures. Patients with unruptured SVA may be symptomatic with exertional dyspnea, palpitations, or chest pain. The sizes of SVA vary from 1 to 10 cm, and they may be associated with ventricular septal defect (11.6%), bicuspid aortic valve (16.3%), or aortic regurgitation (44.2%).4,5 Aneurysm repair can be performed by a direct closure with pledgets or by replacement with a pericardial or Dacron patch.6 The natural history of unruptured SVA has not been clearly defined, and there are no guidelines that indicate the optimal timing of surgery. However, early surgery is recommended because it provides an excellent outcome in such cases, with low operative mortality in noninfected SVA, and because of potentially life-threatening complications.7,8 Funding This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors. Figure 2. Three-dimensional computed tomography showing the aneurysm with a diameter of 21 13 mm, a few millimeters from the valve floor and the ostium of the right coronary artery.
normal functioning of the aortic valve (Figure 3). The postoperative course was uneventful.
Discussion The exact prevalence of SVA is unknown, but an autopsy study of 8138 individuals suggested a prevalence of 0.09% in the general population.3 Unruptured SVA is usually asymptomatic. Symptoms develop when the enlarging aneurysm ruptures or compresses adjacent
Conflict of interest statement None declared.
References 1. Feldman DN and Roman MJ. Aneurysms of the sinuses of Valsalva [Review]. Cardiology 2006; 106: 73–81. 2. Edwards JE and Burchell HB. The pathological anatomy of deficiencies between the aortic root and the heart, including aortic sinus aneurysms. Thorax 1957; 12: 125–139. 3. Smith WA. Aneurysm of the sinus of Valsalva, with report of 2 cases. JAMA 1914;62:1878–80. Available at: http:// jama.jamanetwork.com/Issue.aspx?journalid¼67&issue ID¼11048&direction¼P. Accessed February 01, 2013.
Downloaded from aan.sagepub.com at Virginia Tech on March 14, 2015
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4. Sen T, Guray Y, Hajro E and Demirkan BM. Giant unruptured noncoronary sinus of Valsalva aneurysm with ascending aorta dissection. Eur J Cardiothorac Surg 2009; 36: 187. 5. Takach TJ, Reul GJ, Duncan JM, et al. Sinus of Valsalva aneurysm or fistula: management and outcome. Ann Thorac Surg 1999; 68: 1573–1577. 6. Menon S, Kottayil B, Panicker V, Pillai V, Karunakaran J. Ruptured sinus of Valsalva aneurysm: 10-year Indian surgical experience.
7. Jebara VA, Chauvaud S, Portoghese M, et al. Isolated extracardiac unruptured sinus of Valsalva aneurysms. Ann Thorac Surg 1992; 54: 323–326. 8. Darabian S, Ahmadi SH, Abbasi K, Abbasi A, Shirzad M and Azadi M. Giant unruptured noncoronary sinus of Valsalva aneurysm. J Card Surg 2009; 24: 351–353.
Downloaded from aan.sagepub.com at Virginia Tech on March 14, 2015
Direct closure of an asymptomatic right coronary sinus of Valsalva aneurysm
Asian Cardiovascular & Thoracic Annals 2014, Vol. 22(5) 601–603 ß The Author(s) 2013 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav DOI: 10.1177/0218492313479952 aan.sagepub.com
Giulio Tessitore1, Francesco Alamanni1, Sarah Ghulam Ali2 and Marco Zanobini1
Abstract A 52-year-old man was referred for evaluation of palpitation. Transthoracic echocardiography revealed an extracardiac aneurysm of the right coronary sinus of Valsalva, and normal anatomy of the aortic valve with no regurgitation. Threedimensional computed tomography confirmed the aneurysm with a diameter of 21 13.7 mm arising from the right coronary sinus of Valsalva under the right coronary artery. Surgical repair was performed without changing the normal anatomy of the aortic valve, preserving the right coronary ostium. Intraoperative and postoperative echocardiography showed complete closure of the aneurysm with normal functioning of the aortic valve.
Keywords Aortic aneurysm, sinus of valsalva, echocardiography
Introduction Sinus of Valsalva aneurysm (SVA) is a rare cardiac anomaly that may be acquired or congenital.1 SVA is caused by separation of the aortic media of the sinus from the media adjacent to the hinge line of the aortic valve cusp.2 Acquired aneurysms are caused by conditions affecting the aortic wall, such as infections (syphilis, bacterial endocarditis, or tuberculosis), trauma, or connective tissue disorders. Unruptured SVA is generally asymptomatic and its diagnosis is usually incidental. We describe an asymptomatic unruptured SVA that was treated by direct interrupted pledgeted suturing.
Case report A 52-year-old man was referred to our hospital for evaluation of palpitation, with a history of Becker muscular dystrophy, hypertension, and dyslipidemia. Transthoracic echocardiography revealed an extracardiac aneurysm of the right coronary sinus of Valsalva with normal anatomy of the aortic valve and no aortic regurgitation (Figure 1). Three-dimensional computed tomography confirmed the presence of the aneurysm measuring 21 13.7 mm, arising from the right coronary sinus of Valsalva under the right coronary artery (Figure 2). Coronary angiography also showed the
presence of the aneurysm and critical disease of the intermediate branch of the main coronary artery. A median sternotomy was performed. Cardiopulmonary bypass was instituted between the ascending aorta and right atrium. After cardiac arrest with cold blood cardioplegia, the ascending aorta was transected at the level of the sinotubular junction. The aortic wall of the aneurysm was thin, but the other sinuses had normal thickness. Surgical repair of the valve annulus and right coronary ostium was performed inside the sinus of Valsalva, using 4 interrupted pledgeted sutures, preserving the normal anatomy of the aortic valve and right coronary ostium. The intermediate branch of the main coronary artery was perfused through the left internal thoracic artery. Intraoperative and postoperative echocardiography showed complete closure of the aneurysm with 1 Department of Cardiovascular Surgery, IRCCS Centro Cardiologico Fondazione Monzino, Milan, Italy 2 Department of Cardiovascular Imaging, IRCCS Centro Cardiologico Fondazione Monzino, Milan, Italy
Corresponding author: Giulio Tessitore, Department of Cardiovascular Surgery, Istituto Clinico Citta` Di Alessandria, Via Bruno Buozzi, Alessandria, Italy. Email: [email protected]
Downloaded from aan.sagepub.com at Virginia Tech on March 14, 2015
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Asian Cardiovascular & Thoracic Annals 22(5)
Figure 1. Preoperative transesophageal echocardiography showing the aneurysm of the sinus of Valsalva at the level of the right coronary sinus.
Figure 3. Postoperative echocardiography showing complete closure of the aneurysm.
structures. Patients with unruptured SVA may be symptomatic with exertional dyspnea, palpitations, or chest pain. The sizes of SVA vary from 1 to 10 cm, and they may be associated with ventricular septal defect (11.6%), bicuspid aortic valve (16.3%), or aortic regurgitation (44.2%).4,5 Aneurysm repair can be performed by a direct closure with pledgets or by replacement with a pericardial or Dacron patch.6 The natural history of unruptured SVA has not been clearly defined, and there are no guidelines that indicate the optimal timing of surgery. However, early surgery is recommended because it provides an excellent outcome in such cases, with low operative mortality in noninfected SVA, and because of potentially life-threatening complications.7,8 Funding This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors. Figure 2. Three-dimensional computed tomography showing the aneurysm with a diameter of 21 13 mm, a few millimeters from the valve floor and the ostium of the right coronary artery.
normal functioning of the aortic valve (Figure 3). The postoperative course was uneventful.
Discussion The exact prevalence of SVA is unknown, but an autopsy study of 8138 individuals suggested a prevalence of 0.09% in the general population.3 Unruptured SVA is usually asymptomatic. Symptoms develop when the enlarging aneurysm ruptures or compresses adjacent
Conflict of interest statement None declared.
References 1. Feldman DN and Roman MJ. Aneurysms of the sinuses of Valsalva [Review]. Cardiology 2006; 106: 73–81. 2. Edwards JE and Burchell HB. The pathological anatomy of deficiencies between the aortic root and the heart, including aortic sinus aneurysms. Thorax 1957; 12: 125–139. 3. Smith WA. Aneurysm of the sinus of Valsalva, with report of 2 cases. JAMA 1914;62:1878–80. Available at: http:// jama.jamanetwork.com/Issue.aspx?journalid¼67&issue ID¼11048&direction¼P. Accessed February 01, 2013.
Downloaded from aan.sagepub.com at Virginia Tech on March 14, 2015
Tessitore et al.
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4. Sen T, Guray Y, Hajro E and Demirkan BM. Giant unruptured noncoronary sinus of Valsalva aneurysm with ascending aorta dissection. Eur J Cardiothorac Surg 2009; 36: 187. 5. Takach TJ, Reul GJ, Duncan JM, et al. Sinus of Valsalva aneurysm or fistula: management and outcome. Ann Thorac Surg 1999; 68: 1573–1577. 6. Menon S, Kottayil B, Panicker V, Pillai V, Karunakaran J. Ruptured sinus of Valsalva aneurysm: 10-year Indian surgical experience.
7. Jebara VA, Chauvaud S, Portoghese M, et al. Isolated extracardiac unruptured sinus of Valsalva aneurysms. Ann Thorac Surg 1992; 54: 323–326. 8. Darabian S, Ahmadi SH, Abbasi K, Abbasi A, Shirzad M and Azadi M. Giant unruptured noncoronary sinus of Valsalva aneurysm. J Card Surg 2009; 24: 351–353.
Downloaded from aan.sagepub.com at Virginia Tech on March 14, 2015
