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J Thorac Cardiovasc Surg 2004;127:1823-1825
© 2004 The American Association for Thoracic Surgery

Brief communication

Repair of a sinus of Valsalva aneurysm that had ruptured into the pulmonary artery

Heyman Luckraz, FRCSa,*, Madhav Naik, FRCSa, Geraint Jenkins, MRCPb, Aprim Youhana, FRCSa

a Cardiothoracic Unit, Regional Cardiac Centre, Morriston Hospital, Swansea, UK
b Cardiology Department, Regional Cardiac Centre, Morriston Hospital, Swansea, UK

Received for publication November 18, 2003; accepted for publication November 24, 2003.

* Address for reprints: Heyman Luckraz, FRCS, Cardiothoracic Unit, Morriston Hospital, Swansea SA6 6NL, UK
HeymanLuckraz{at}aol.com


Youhana, Jenkins, Naik, Luckraz (left to right)


Thus far, less than 500 cases of aneurysmal rupture of the sinus of Valsalva have been reported in the literature,1 despite being first reported by Hope in 1839. The reported prevalence is between 0.14% and 0.96%.1 Most commonly, the clinical presentation follows the rupture of the aneurysm, although patients without rupture can present with symptoms of a space-occupying lesion causing angina, mitral incompetence, aortic incompetence, and right ventricular outflow tract obstruction.

Surgical repairs were first described independently by Morrow and colleagues2 in 1958 and Bigelow and Barnes3 in 1959. Two years earlier, Edwards and Burchell4 had published a detailed anatomicopathologic review of aneurysms of the aortic sinus. They described the lesion as being a separation between the aortic media and the heart. This might be due to either a congenital deficiency in the development of the media of the distal bulbar septum or an acquired medial degeneration caused by atherosclerosis, syphilis, and infection.

A review of 129 patients by Takach and coworkers1 revealed that the most common site of rupture is into the right ventricle. Although rupture in the other cardiac chambers and intrapericardial rupture have been described in the literature, rupture into the main pulmonary artery is very rare.

We describe our experience with such a case.

Clinical summary

A 79-year-old man was admitted with an episode of sudden onset of severe chest pain radiating to his upper back and shortness of breath. Clinically, he was hemodynamically stable but had a precordial machinery murmur with evidence of moderate pulmonary edema. Transthoracic echocardiography confirmed an aneurysm and rupture of the sinus of Valsalva which is associated with the right coronary cusp (Figure 1). Right-heart catheterization revealed a step up in oxygen saturation from 60% in the right ventricle to 82% in the main pulmonary artery, with an aortic oxygen saturation of 98%. The measured pulmonary pressure was 43/13 mm Hg, with the systemic pressure being 116/52 mm Hg.



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  		Figure 1. Transthoracic echocardiography showing the level of the aneurysmal rupture (A) with an abnormal jet (J) of blood from the aortic root to the main pulmonary artery.

 
The patient underwent surgical repair of the ruptured sinus. Operative findings included a dilated right ventricle, a palpable thrill over the main pulmonary trunk, and aneurysmal dilatation of the sinus of Valsalva associated with the right coronary cusp, which had ruptured into the main pulmonary artery (Figure 2). The aortic valve appeared structurally normal, and no other abnormalities were detected.



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  		Figure 2. View through the aortotomy showing the neck of the sinus of Valsalva aneurysm (A) with the surgical instrument through the ruptured wall (B) into the pulmonary artery.

 
The neck of the aneurysm was plicated with a 5-0 Prolene stitch (Ethilon, Johnson and Johnson International). The wall of the sinus of Valsalva was reinforced with a double velour fabric patch (Bard Debakey, IMPRA, Inc) secured with 5-0 Prolene continuous stitches. Cardiac activity resumed spontaneously (sinus rhythm) after the release of the aortic crossclamp, and the cardiopulmonary bypass circuit was discontinued with the inotropic support of dopamine.

The patient had acute renal failure requiring renal replacement therapy from the second to the fifth postoperative days. Thereafter, he had an uneventful recovery and was discharged home 10 days after his emergency surgical procedure.

An echocardiogram before discharge confirmed successful repair of the rupture.

Discussion

Rupture of the right aortic sinus into the pulmonary artery, as in the presented case, is an uncommon finding. This most likely represent an anatomic variation of the structures associated with the right aortic sinus. In their detailed report concerning the anatomic relationship of various aortic sinuses, Edwards and Burchell4 described the right aortic sinus as being entirely related to the right ventricular outflow tract. For descriptive purposes, the right aortic sinus is divided in thirds, with the central third lying against the crista supraventricularis. The left (anterior) third of the sinus abuts the right ventricular outflow tract close to the pulmonary valve, whereas the posterior third lies against the right ventricle posteroinferior to the crista supraventricularis. The sinus associated with the right coronary cusp is more commonly affected and is also more likely to rupture, whereas the opposite is true for sinus of the left coronary cusp. The sites of communication, in decreasing order, are the right ventricle, right atrium, left atrium, left ventricle, and pericardium.

The natural history of the aneurysmal dilatation of the sinus of Valsalva is not completely understood. Patients with untreated ruptures have been reported to survive an average of nearly 4 years.5 Surgical treatment is usually associated with low mortality and excellent long-term outcome.1 Surgical intervention is recommended in both ruptured and nonruptured cases, especially if there are symptoms of a space-occupying lesion. Management strategies involve plication, patch repair, aortic valve surgery, and aortic root replacement with reimplantation of the coronary arteries.

References

  1. Takach TJ, Reul GJ, Duncan JM, Cooley DA, Livesay JJ, Ott DA, et al. Sinus of Valsalva aneurysm or fistula: management and outcome. Ann Thorac Surg. 1999;68:1573–1577[Abstract/Free Full Text]
  2. Morrow AG, Baker RR, Hanson HE. Successful surgical repair of a ruptured aneurysm of the sinus of Valsalva. Circulation. 1958;24:533–538
  3. Bigelow WG, Barnes WT. Ruptured aneurysm of aortic sinus. Ann Surg. 1959;150:117–121[Medline]
  4. Edwards JE, Burchell HB. The pathological anatomy of deficiencies between the aortic root and the heart, including aortic sinus aneurysms. Thorax. 1957;12:125–139
  5. Sawyers JL, Adams JE, Scott SW Jr. Surgical treatment for aneurysms of the aortic sinuses with aorticoatrial fistula: experimental and clinical study. Surgery. 1975;41:46–48



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