Eur J Cardio-thorac

41

Surg (1992) 6: 15-17

European Journal of

[email protected] SWPY 0 Springer-Verlag1992

Ruptured aneurysms of the sinus of Valsalva L. LukBcs, 1. Bartek, A. Hahn, J. Hankbczy,

and A. Arvay

Hungarian Institute of Cardiology, Budapest, Hungary

Abstract. 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. [Eur J Cardio-thorac Surg (1992) 6:15-171 Key words: Sinus of Valsalva

- Ventricular

septal defect - Aortic

A ruptured aneurysm of the sinus of Valsalva has been considered to be a very rare cardiac lesion. The rupture results in a fistulous connection between the aorta and a contiguous structure, most often the right atrium or right ventricle [8, 10, 111. Its incidence in all operative interventions employing cardiopulmonary bypass is reported to range from 0.14%-0.96% [I, 5, 81. Possible causes of aneurysmal dilatation of the aortic sinuses include congenital, bacterial or mycotic infection, syphilis, and cystic medical necrosis [2,6,7,9]. The lesion is usually manifest in the 1st to 5th decade and has a wide spectrum of symptoms. Our 15 cases are considered as being of congenital origin and the other types of aneurysm will not be discussed.

Material

and methods

Between 1969 and 1989, a total of 15 consecutive patients with this lesion have been operated upon in our Department of Surgery (Table 1). This represents 0.23% of 6515 cardiac operations using cardiopulmonary bypass for that period. There were 8 males and 7 females ranging in age from 15 to 54 years (mean 35.8 f 11.3 years). Received for publication: Accepted for publication:

May 8, 1991 October 3, 1991

regurgitation

- Congenital

heart anomalies

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). Associated cardiovascular anomalies were present in 9 patients and consisted of ventricular septal defect (3 patients) and aortic valve incompetence (6 patients). The ventricular septal defects were supracristal infundibular in 2 cases and perimembraneous in 1 case. In the 3 cases with a ventricular septal defect, all had an aneurysm from the right coronary sinus and all ruptured into the right ventricle. The predominant symptoms were fatigue, palpitation, dyspnea and chest pain. None had a history of bacterial endocarditis. Peripheral edema was present in 3 patients. New York Heart Association (NYHA) functional class for patients at the time of diagnosis is shown in Fig. 1. In all patients, a loud continuous murmur was heard in the 3rd or 4th intercostal space along the left sternal border. A widened pulse pressure was observed in the majority of patients. Mean preoperative pulse pressure was 94.6 + 33.8 mm Hg. Chest roentgenograms showed cardiac enlargement of varying degree and pulmonary plethora. The ECG patterns varied: left or biventricular hypertrophy was usually present. All patients were in sinus rhythm. Preoperative cardiac catheterization and angiocardiography was performed in all patients. Pulmonary artery systolic pressure ranged from 28 mm Hg to 60 mm Hg (mean 42.8 + 10.2 mm Hg). All patients had calculated Qp/Q, values ranging from 1.8 to 2.8 (mean 2.1 kO.3). Retrograde aortography demonstrated typical deformity of the aortic sinus with concomitant opacification of the right side of the heart. Six of 15 patients also had aortic valve regurgitation

16 Table 1. Patients with a ruptured

aneurysm of the sinus of Valsalva

Patient

Age (years)

Sex

Time interval between onset of symptoms and operation (months)

Fistula

Coexistent lesion

Surgical approach

Follow-up (years)

1 2 3 4 5 6 7 8 9 10 11

28 41 15 29 24 32 23 50 29 41 35

F M F M F M F F M M F

18 14 20 15 1 120 2 4 12 10 4

_ AI AI VSD VSD AI VSD AI AI

RA RV RV RA Ao+RV Ao+RV Ao+RV Ao+RA Ao+RV Ao+RV Ao+RA

20.5 20.0 19.2 16.2 13.7 10.5 9.6 9.0 9.0 5.6 3.3

12

54

M

5

AI

Ao+RA

2.6

13 14 15

35 42 46

M F M

2 1 6

NS-RA RS-RV RS-RV NS-RA RS-RV RS-RV RS-RV NS-RA RS-RV RS-RV NS-RA RA RS’RV NS-RA NS-RA RS-RV

_ _ _

Ao+RA Ao+RA Ao+RV

0.9 0.7 0.5

M = male; F = female; NS = noncoronary sinus; RS = right VSD = ventricular septal defect; AI = aor& insufficiency _

coronary

based on retrograde aortography. A mild degree of aortic valve imcompetence was estimated to be present in 4 cases and a moderate degree in 2 cases. The latter 2 patients were in NYHA class III and IV and had calcific aortic valve disease. The patients were operated upon with the aid of cardiopulmonary bypass and moderate systemic hypothermia. From 1979, cold (4 “C) potassium crystalloid cardioplegic solution and topical hypothermia were used for myocardial protection. The standard incision was a median sternotomy. A right atria1 or ventricular approach was the method of choice in the early period (4 cases). The projecting aneurysmal sac was resected at its base followed by direct closure with pledgeted mattress sutures. Recently, the aneurysm has been repaired via aortotomy and through the chamber into which it emptied (11 cases). This exposure minimizes the risk of distorting the aortic cusps. The ventricular septal defects were closed with patch through the aorta (1 patient) and through the right ventricle (2 patients). The calcified aortic valve was placed in 2 patients with a 23 mm St. Jude Medical prosthetic valve. The aneurysm was repaired first and then valve replacement was performed. The time interval between onset of symptoms and surgical repair was I- 120 months (mean 15.7 + 36.8 months).

sinus;

RA= right

atrium;

RV = right

ventricle;

Ao = aorta;

NYHA I

NYHA II

NYHA Ill

NYHA IV

Fig. 1. New York Heart Association diagnosis and follow-up

(NYHA) functional

class at

Discussion Results

There were no early or late postoperative deaths. Two patients required early reoperation for evacuation of a hemothorax. All patients were followed-up from 0.5 to 20.5 years (mean 8.7k6.8 years). There have been no recurrences in the follow-up period. The NYHA functional class for patients at follow-up is depicted in Fig. 1. Fourteen patients are in NYHA functional class I. One patient who had aortic valve replacement because of calcified aortic valve disease and moderate aortic valve regurgitation is in NYHA functional class II. In 4 patients with mild aortic insufficiency who did not have aortic valve replacement at the time of repair, the degree of regurgitation remained unchanged after a mean of 10.5 years. Mean postoperative pulse pressure was 53.2 k 10.5 mmHg as compared to the preoperative values of 94.6f33.8 mmHg (P

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 operati...
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