Gen Thorac Cardiovasc Surg DOI 10.1007/s11748-014-0410-1
CASE REPORT
Rapid expansion of mycotic aneurysm of left coronary sinus of Valsalva causing myocardial ischemia: report of a case Naoto Morimoto • Naritomo Nishioka • Masato Yoshida • Nobuhiko Mukohara
Received: 24 January 2014 / Accepted: 17 April 2014 Ó The Japanese Association for Thoracic Surgery 2014
Abstract 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. Keywords aneurysm
Aneurysm of left sinus of Valsalva Mycotic
Introduction Isolated unruptured aneurysms of the sinus of Valsalva are rare and may result in coronary insufficiency [1]. We report a patient in whom rapid expansion of a saccular mycotic aneurysm of the left coronary sinus of Valsalva over 6 days caused ventricular fibrillation and myocardial ischemia. The patient was successfully treated with emergent aortic root replacement.
Case presentation A 71-year-old woman was admitted to our institution with fever lasting 3 days. She had underwent combined N. Morimoto (&) N. Nishioka M. Yoshida N. Mukohara Division of Cardiovascular Surgery, Hyogo Brain and Heart Center, 520, Saishoko, Himeji, Hyogo 650-0017, Japan e-mail: [email protected]
replacement of aortic valve and ascending aorta using a 21-mm-sized mechanical valve and Dacron tube graft 11 years ago. At that time, the aortic valve was bicuspid and the diameter of Valsalva sinus was 38 mm. On admission, she had a low-grade fever. Laboratory examination showed the elevations in white blood cell count (10.7 9 103/ml) and C-reactive protein (11.21 mg/dl). Contrast-enhanced computed tomography revealed localized staining adjacent to the left sinus of Valsalva (Fig. 1a). Although transthoracic echocardiography did not show any evidence of prosthetic valve endocarditis, she was treated with vancomycin and gentamicin for suspected endocarditis because all four blood cultures had grown Staphylococcus aureus. Transesophageal echocardiography performed on the fourth day after the admission revealed a 23 9 37 mm sized aneurysm of the left sinus of Valsalva, but there were no vegetations on the mechanical valve. Repeat enhanced computed tomography showed the saccular aneurysm growing between the mechanical aortic prosthesis and left main trunk (Fig. 1b–d). Although she had been scheduled for urgent surgical repair, she suddenly developed ventricular fibrillation on the sixth day morning. After defibrillation, her electrocardiogram showed sinus rhythm with anterior ST elevation. An intraaortic balloon pump was inserted before anesthetic induction. Emergency surgery revealed a 40 mm 9 40 mm sized aneurysm of the left-coronary sinus of Valsalva with mural thrombus laying behind the proximal ascending aorta. A hole communicating with the aneurysm located in the left-coronary sinus of Valsalva, 5 mm from the sewing ring of the aortic prosthesis and 1 cm from the ostium of the left coronary artery. Neither valvular detachment nor vegetation was found upon direct visual inspection. The aneurysm was completely excised together with the left coronary sinus wall. After removing the aortic prosthesis, aortic root replacement was performed using 23-mm-sized stentless
123
Gen Thorac Cardiovasc Surg Fig. 1 Preoperative multidetector-row computed tomography demonstrated an aneurysm in the left posterior aortic root. Aximal image of CT performed on the fifth day (b) showed enlargement of the aneurysm compared to that on the first day (a). Endoluminal view showed the hole (asterisk) communicating to the aneurysm was located in the left coronary sinus of Valsalva (d)
bioprosthesis (Freestyle, Medtronic, Inc, Minneapolis, MN, USA). Proximal anastomosis was performed by interrupted sutures. The distal portion of bioprosthesis was extended using Intergard knitted polyester vascular graft (Intervascular Inc., Montvale, NJ, USA). The cuff of left coronary artery, not involved by the infection, was attached to bioprosthesis using autologous pericardium as the reinforcement. During aortic cross-clamping, cardiac arrest was obtained by antegrade infusion of cold blood cardioplegia and was maintained by retrograde continuous infusion via coronary sinus. Staphylococcus aureus was detected in the mural thrombus of the aneurysm. The histologic specimens showed an organized thrombus adherent to the aneurysm wall with completely destroyed intima and disrupted internal elastic lamina, confirming the mycotic aneurysm. Postoperative maximum serum levels of creatinine kinase and creatinine kinase isozyme MB were 3,980 and 578 IU/l, respectively. Administration of vancomycin was continued for 8 weeks following surgery. The postoperative course was uneventful without recurrence of infection. She has remained well 2 years after surgery.
123
Discussion The aneurysms of sinus of Valsalva are rare anomalies. The location of the aneurysm is in the right coronary sinus in 94 %, the non-coronary sinus in 5 %, and the left coronary sinus in 1 % [1]. Although unruptured aneurysms of the sinus of Valsalva are typically asymptomatic, these aneurysms could protrude and rupture into the myocardium, the neighboring cardiac chamber, or free pericardium [2]. The compression of the left coronary artery by the aneurysm of the left coronary sinus of Valsalva can cause myocardial ischemia. Lijoi and associates [3] reviewed 19 cases, in which unruptured aneurysm of the left sinus of Valsalva had hindered the coronary arterial flow. The aneurysm was congenital in 10 patients and acquired in 9 (syphilic in 1, connective tissue disorder in 4, and mycotic in 4). Nine of 19 patients underwent surgery with various techniques such as direct or patch closure of the opening of the aneurysm, replacement of the aortic valve, coronary artery bypass grafting or a combination of these. However, when the cause of aneurysm is mycotic or connective tissue disorder,
Gen Thorac Cardiovasc Surg
the diseased wall of the sinus of Valsalva should be excised and replaced. We performed aortic root replacement. The dynamic obstruction of coronary flow due to aneurysm of the sinus of Valsalva is an uncommon manifestation. There is more risk of myocardial ischemia in aneurysm of the left coronary sinus of Valsalva than in the right coronary sinus of Valsalva because the left coronary sinus aneurysm can protrude between the left atrium and the pulmonary trunk, compressing the left coronary artery. In contrast, obstruction of right coronary artery occurs due to the presence of thrombus or syphilitic involvement, and mechanical deformation of the ostium and/or proximal compression from the right coronary sinus aneurysm is less frequent [4]. Faillace and associates [5] reported the case of rapid expansion of saccular aneurysm of the left coronary sinus of Valsalva causing death due to direct compression of the left main coronary artery. The clinical course was similar to the present case. We conclude that emergent surgical repair of saccular aneurysm of the left sinus of Valsalva from the mycotic origin should be considered because a delay of surgery could be fatal.
Conflict of interest Naoto Morimoto, Naritomo Nishioka, Masato Yoshida and Nobuhiko Mukohara have no conflict of interest.
References 1. Mukohara N. Unruptured aneurysm of the right coronary sinus of Valsalva: case report and review of literature. Gen Thorac Cardiovasc Surg. 2013;61:147. 2. Chu SH, Hung CR, How SS, Chang H, Wang SS, Tsai CH, et al. Ruptured aneurysms of the sinus of Valsalva in oriental patients. J Thorac Cardiovasc Surg. 1990;99:288–98. 3. Lijoi A, Parodi E, Passerone GC, Scarano F, Caruso D, Iannetti MV. Unruptured aneurysm of the left sinus of Valsalva causing coronary insufficiency. Tex Heart Inst J. 2002;29:40–4. 4. Abel MR, Lado MP, Ciudad VL, Beiras AC. Sinus of Valsalva aneurysm as a cause of acute myocardial infarction. Rev Esp Cardiol. 2002;55:77–9. 5. Faillace RT, Greenland P, Nanda NC. Rapid expansion of a saccular aneurysm on the left coronary sinus of Valsalva: a role for early surgical repair? Br Heart J. 1985;54:442–4.
123
CASE REPORT
Rapid expansion of mycotic aneurysm of left coronary sinus of Valsalva causing myocardial ischemia: report of a case Naoto Morimoto • Naritomo Nishioka • Masato Yoshida • Nobuhiko Mukohara
Received: 24 January 2014 / Accepted: 17 April 2014 Ó The Japanese Association for Thoracic Surgery 2014
Abstract 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. Keywords aneurysm
Aneurysm of left sinus of Valsalva Mycotic
Introduction Isolated unruptured aneurysms of the sinus of Valsalva are rare and may result in coronary insufficiency [1]. We report a patient in whom rapid expansion of a saccular mycotic aneurysm of the left coronary sinus of Valsalva over 6 days caused ventricular fibrillation and myocardial ischemia. The patient was successfully treated with emergent aortic root replacement.
Case presentation A 71-year-old woman was admitted to our institution with fever lasting 3 days. She had underwent combined N. Morimoto (&) N. Nishioka M. Yoshida N. Mukohara Division of Cardiovascular Surgery, Hyogo Brain and Heart Center, 520, Saishoko, Himeji, Hyogo 650-0017, Japan e-mail: [email protected]
replacement of aortic valve and ascending aorta using a 21-mm-sized mechanical valve and Dacron tube graft 11 years ago. At that time, the aortic valve was bicuspid and the diameter of Valsalva sinus was 38 mm. On admission, she had a low-grade fever. Laboratory examination showed the elevations in white blood cell count (10.7 9 103/ml) and C-reactive protein (11.21 mg/dl). Contrast-enhanced computed tomography revealed localized staining adjacent to the left sinus of Valsalva (Fig. 1a). Although transthoracic echocardiography did not show any evidence of prosthetic valve endocarditis, she was treated with vancomycin and gentamicin for suspected endocarditis because all four blood cultures had grown Staphylococcus aureus. Transesophageal echocardiography performed on the fourth day after the admission revealed a 23 9 37 mm sized aneurysm of the left sinus of Valsalva, but there were no vegetations on the mechanical valve. Repeat enhanced computed tomography showed the saccular aneurysm growing between the mechanical aortic prosthesis and left main trunk (Fig. 1b–d). Although she had been scheduled for urgent surgical repair, she suddenly developed ventricular fibrillation on the sixth day morning. After defibrillation, her electrocardiogram showed sinus rhythm with anterior ST elevation. An intraaortic balloon pump was inserted before anesthetic induction. Emergency surgery revealed a 40 mm 9 40 mm sized aneurysm of the left-coronary sinus of Valsalva with mural thrombus laying behind the proximal ascending aorta. A hole communicating with the aneurysm located in the left-coronary sinus of Valsalva, 5 mm from the sewing ring of the aortic prosthesis and 1 cm from the ostium of the left coronary artery. Neither valvular detachment nor vegetation was found upon direct visual inspection. The aneurysm was completely excised together with the left coronary sinus wall. After removing the aortic prosthesis, aortic root replacement was performed using 23-mm-sized stentless
123
Gen Thorac Cardiovasc Surg Fig. 1 Preoperative multidetector-row computed tomography demonstrated an aneurysm in the left posterior aortic root. Aximal image of CT performed on the fifth day (b) showed enlargement of the aneurysm compared to that on the first day (a). Endoluminal view showed the hole (asterisk) communicating to the aneurysm was located in the left coronary sinus of Valsalva (d)
bioprosthesis (Freestyle, Medtronic, Inc, Minneapolis, MN, USA). Proximal anastomosis was performed by interrupted sutures. The distal portion of bioprosthesis was extended using Intergard knitted polyester vascular graft (Intervascular Inc., Montvale, NJ, USA). The cuff of left coronary artery, not involved by the infection, was attached to bioprosthesis using autologous pericardium as the reinforcement. During aortic cross-clamping, cardiac arrest was obtained by antegrade infusion of cold blood cardioplegia and was maintained by retrograde continuous infusion via coronary sinus. Staphylococcus aureus was detected in the mural thrombus of the aneurysm. The histologic specimens showed an organized thrombus adherent to the aneurysm wall with completely destroyed intima and disrupted internal elastic lamina, confirming the mycotic aneurysm. Postoperative maximum serum levels of creatinine kinase and creatinine kinase isozyme MB were 3,980 and 578 IU/l, respectively. Administration of vancomycin was continued for 8 weeks following surgery. The postoperative course was uneventful without recurrence of infection. She has remained well 2 years after surgery.
123
Discussion The aneurysms of sinus of Valsalva are rare anomalies. The location of the aneurysm is in the right coronary sinus in 94 %, the non-coronary sinus in 5 %, and the left coronary sinus in 1 % [1]. Although unruptured aneurysms of the sinus of Valsalva are typically asymptomatic, these aneurysms could protrude and rupture into the myocardium, the neighboring cardiac chamber, or free pericardium [2]. The compression of the left coronary artery by the aneurysm of the left coronary sinus of Valsalva can cause myocardial ischemia. Lijoi and associates [3] reviewed 19 cases, in which unruptured aneurysm of the left sinus of Valsalva had hindered the coronary arterial flow. The aneurysm was congenital in 10 patients and acquired in 9 (syphilic in 1, connective tissue disorder in 4, and mycotic in 4). Nine of 19 patients underwent surgery with various techniques such as direct or patch closure of the opening of the aneurysm, replacement of the aortic valve, coronary artery bypass grafting or a combination of these. However, when the cause of aneurysm is mycotic or connective tissue disorder,
Gen Thorac Cardiovasc Surg
the diseased wall of the sinus of Valsalva should be excised and replaced. We performed aortic root replacement. The dynamic obstruction of coronary flow due to aneurysm of the sinus of Valsalva is an uncommon manifestation. There is more risk of myocardial ischemia in aneurysm of the left coronary sinus of Valsalva than in the right coronary sinus of Valsalva because the left coronary sinus aneurysm can protrude between the left atrium and the pulmonary trunk, compressing the left coronary artery. In contrast, obstruction of right coronary artery occurs due to the presence of thrombus or syphilitic involvement, and mechanical deformation of the ostium and/or proximal compression from the right coronary sinus aneurysm is less frequent [4]. Faillace and associates [5] reported the case of rapid expansion of saccular aneurysm of the left coronary sinus of Valsalva causing death due to direct compression of the left main coronary artery. The clinical course was similar to the present case. We conclude that emergent surgical repair of saccular aneurysm of the left sinus of Valsalva from the mycotic origin should be considered because a delay of surgery could be fatal.
Conflict of interest Naoto Morimoto, Naritomo Nishioka, Masato Yoshida and Nobuhiko Mukohara have no conflict of interest.
References 1. Mukohara N. Unruptured aneurysm of the right coronary sinus of Valsalva: case report and review of literature. Gen Thorac Cardiovasc Surg. 2013;61:147. 2. Chu SH, Hung CR, How SS, Chang H, Wang SS, Tsai CH, et al. Ruptured aneurysms of the sinus of Valsalva in oriental patients. J Thorac Cardiovasc Surg. 1990;99:288–98. 3. Lijoi A, Parodi E, Passerone GC, Scarano F, Caruso D, Iannetti MV. Unruptured aneurysm of the left sinus of Valsalva causing coronary insufficiency. Tex Heart Inst J. 2002;29:40–4. 4. Abel MR, Lado MP, Ciudad VL, Beiras AC. Sinus of Valsalva aneurysm as a cause of acute myocardial infarction. Rev Esp Cardiol. 2002;55:77–9. 5. Faillace RT, Greenland P, Nanda NC. Rapid expansion of a saccular aneurysm on the left coronary sinus of Valsalva: a role for early surgical repair? Br Heart J. 1985;54:442–4.
123
