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Case Study

Partial aortic root replacement for aneurysm of the right sinus of Valsalva

Asian Cardiovascular & Thoracic Annals 0(0) 1–3 ß The Author(s) 2014 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav DOI: 10.1177/0218492314522635 aan.sagepub.com

Hiroaki Osada1, Masahisa Kyogoku2, Takahisa Fujino3 and Hiroyuki Nakajima1

Abstract An aneurysm of the sinus of Valsalva is clinically rare, and its operative indications and procedures are controversial. We herein report the rare case of a 68-year-old woman with severe right ventricular outflow tract obstruction caused by an aneurysm of the right sinus of Valsalva. We performed partial aortic root reconstruction using a bovine pericardial patch, and aortic valve replacement. Although this case provides evidence that these are suitable surgical techniques for treatment of aneurysm of the sinus of Valsalva, total aortic root replacement should have been chosen based on the pathological finding of aortic medial and valve degeneration.

Keywords Aortic aneurysm, Aortic valve insufficiency, Sinus of Valsalva, Ventricular outflow obstruction

Introduction An aneurysm of the sinus of Valsalva is clinically rare, and its operative indications and procedures are controversial. We herein describe the surgical repair of an unruptured aneurysm of the right sinus of Valsalva that induced right ventricular outflow tract obstruction (RVOTO) in an elderly woman.

Case report A 68-year-old woman without any known connective tissue disorders was referred to our institution for surgical release of RVOTO due to an unruptured 42-mmdiameter aneurysm of the right sinus of Valsalva (Figure 1). She had a recent history of gradually worsening general fatigue. Preoperatively, her EuroSCORE was calculated 2.23%. There was a trivial to mild amount of aortic valve regurgitation. Right heart catheterization showed a right ventricular systolic pressure of 80 mm Hg and main pulmonary artery systolic pressure of 20 mm Hg. Coronary angiography showed severe (90%) stenosis of the proximal left anterior descending artery. The wall of the aneurysm was extremely thin; it was completely resected towards the bottom of

the aortic root. The aortic valve was tricuspid but degenerated. The right coronary cusp in particular had some fenestrations. Because of the inevitable progression to future aortic insufficiency, aortic valve replacement was selected. On the noncoronary and left coronary annulus and commissures, 10 pairs of everted mattress sutures were passed from the aortic side to the ventricular side. A bovine pericardial patch (Edwards Lifesciences, Irvine, CA, USA) was trimmed (30-mm width), and 6 pairs of U sutures were passed from the bottom of the patch to the right coronary annulus. A 19-mm bovine pericardial bioprosthesis (Edwards Lifesciences) was then tied down. The patch and remaining sinuses were sutured (Figure 1). The right coronary artery orifice was implanted as a button to the pericardial patch, and 1

Department of Cardiovascular Surgery, Mitsubishi Kyoto Hospital, Japan Department of Pathology, Mitsubishi Kyoto Hospital, Japan 3 Department of Cardiology, Kyoto Min-iren Chuo Hospital, Japan 2

Corresponding author: Hiroaki Osada, MD, Department of Cardiovascular Surgery, Mitsubishi Kyoto Hospital, 1 Katsuragoshomachi, Nishikyo-ku, Kyoto 615-8087, Japan. Email: [email protected]

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Figure 1. (a) Enhanced computed tomography showing right ventricular outflow tract obstruction due to the aneurysm. (b) Postoperative computed tomography demonstrating that the aneurysm of the right sinus of Valsalva had been removed. (c–g) Histopathology of the aneurysmal wall. Fragmentation of the elastic lamina (grade 3) and marked compensatory fibrosis (grade 3) are quite evident in (c–e). Sclerosis of the vasa vasorum in (e) was another important pathological finding. Atrophy of smooth muscle cells (grade 3) and fibrosis (grade 3) are evident in (e) and (f). A small cystic accumulation of acid mucopolysaccharide (grade 2) is evident in (g). Original powers of magnification are given on each micrograph. AB: Alcian blue; EVG: elastica van Gieson; MT: Masson’s trichrome.

Figure 2. Fragmentation of the elastic lamina of the adjacent aortic wall is clear in (a) and (b) (grade 3), and compensatory fibrosis is seen in (c) (grade 2). Atrophy of smooth muscle cells (grade 3) surrounded by increased collagen fibers can also be seen in (c), and somewhat cystic accumulation of acid mucopolysaccharide in the media (grade 2) was confirmed in (d). Including sclerosis of the vasa vasorum seen in (e), these findings are quite similar to those of the aneurysmal wall. (f) The structure of the right aortic valve leaflet was invaded by an unusual number of clustering clear cells, mostly on the sinus side. (g, i) The clear substance is acid mucopolysaccharide, and (h) the cells are not neoplastic but degenerative. Original powers of magnification are given on each micrograph. AB: Alcian blue; EVG: elastica van Gieson; HE: hematoxylin-eosin; MT: Masson’s trichrome.

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aortocoronary bypass was performed on the left anterior descending artery with a saphenous vein graft (because the internal mammary arteries were hypoplastic). On the 18th postoperative day, the patient was discharged with no sequelae. Pathological examination of the extremely thin aneurysmal wall revealed marked smooth muscle atrophy, fragmentation of the elastic lamina with compensatory fibrosis, and augmentation of an Alcian blue-positive substance (Figure 1). Furthermore, part of the aortic wall adjacent to the right sinus of Valsalva, which had appeared normal on visual inspection, demonstrated marked medial degeneration, almost identical to that of the aneurysmal wall (Figure 2). Two additional important pathological findings were observed: sclerosis of the vasa vasorum running through the adventitia to the outer part of the media in both the aortic wall and the aneurysmal wall, and severe myxoid degeneration of the aortic valve, affecting all 3 leaflets (Figure 2). All specimens were reviewed with reference to criteria based on the report by Schlatmann and Becker.1

as the aneurysmal wall, which may have occurred secondary to an ischemic or alimentary disturbance due to sclerosis of the same vasa vasorum.4 Although David3 reported that nondiseased walls do not require resection, it is difficult to judge whether the wall is normal based only on visual inspection. Considering the pathological picture in this case, there is a possibility that the remaining two sinus walls may also have been affected by the same pathological changes and may progress to a diseased state in the future. Therefore, total aortic root replacement, such as the Bentall procedure, may have been required in this case because of the risk of future aneurysmal change or dissection. Continuous observational follow-up must be implemented. Although partial aortic root replacement is currently a suitable surgical technique for this case, the postoperative pathological results demonstrated that future aneurysmal change or dissection of the remaining sinus of Valsalva or ascending aorta is possible. Funding This research received no specific grant from any funding agency in the public, commerical, or not-for-profit sectors.

Discussion The operative indications and procedures for aneurysms of the sinus of Valsalva are mostly based on which and how many sinuses of Valsalva are involved. Fukui and colleagues2 reported a single patch technique using a Dacron graft and aortic valve replacement for unruptured aneurysm of the right sinus of Valsalva in 2008, and other reports have described several techniques for similar conditions. In our patient, the diseased right sinus of Valsalva was completely resected. Because the remaining sinuses of Valsalva seemed to be normal, we spared the noncoronary and left coronary sinuses of Valsalva, based on the report of David3 who spared the normal aortic sinuses and replaced thinned and dilated aortic sinuses in his series of aortic root aneurysms. The postsurgical pathological results revealed that the apparently normal aortic wall was already quite degenerated to almost the same degree

Conflict of interest statement None declared

References 1. Schlatmann TJ and Becker AE. Pathogenesis of dissecting aneurysm of aorta. Comparative histopathologic study of significance of medial changes. Am J Cardiol 1977; 39: 21–26. 2. Fukui S, Mitsuno M, Yamamura M, et al. Successful repair of unruptured aneurysm of the right sinus of Valsalva. Ann Thorac Surg 2008; 86: 640–643. 3. David TE. Aortic root aneurysm: remodeling or composite replacement? Ann Thorac Surg 1997; 64: 1564–1568. 4. Osada H, Kyogoku M, Ishidou M, Morishima M and Nakajima H. Aortic dissection in the outer third of the media; What is the role of the vasa vasorum in the triggering process? Eur J Cardiothorac Surg 2013; 43: e82–e88.

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Partial aortic root replacement for aneurysm of the right sinus of Valsalva.

An aneurysm of the sinus of Valsalva is clinically rare, and its operative indications and procedures are controversial. We herein report the rare cas...
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