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J Thorac Cardiovasc Surg 2009;137:e37-e39
© 2009 The American Association for Thoracic Surgery
Brief Communication |
a Department of Cardiovascular Surgery, Nakagami Hospital, Okinawa, Japan
b Department of Cardiology, Nakagami Hospital, Okinawa, Japan
Received for publication April 24, 2008; accepted for publication July 5, 2008. * Address for reprints: Jiro Honda, MD, Department of Cardiovascular Surgery, Nakagami Hospital, 6–25–5 Chibana, Okinawa-city, Okinawa 904–2195, Japan. (Email: j-honda{at}cardio-vasc.com).
Congenital sinus of Valsalva aneurysm is uncommon. The rupture results in a fistulous connection between the aorta and any cardiac chamber. This report describes a patient with a ruptured aneurysm of the right sinus of Valsalva that extended to the right ventricle, crossed over the pulmonary valve, and protruded into the main pulmonary artery. The aneurysm obstructed the right ventricular outflow tract (RVOT) and made a pressure gradient between the right ventricle and the pulmonary artery. The top of the aneurysmal sac had a ruptured hole opening in the pulmonary artery that caused an aortopulmonary shunt. To the best of our knowledge, no other cases with these features have been reported in the medical literature.
A 46-year-old man presented with dyspnea on exertion, which he had experienced for the past several years. A heart murmur had been diagnosed in the patient at the age of 7 years. A ventricular septal defect was suspected, but the patient had not undergone a checkup because he had no symptoms. On presentation, he was in New York Heart Association class II.
Transthoracic echocardiography revealed an aneurysm of the right sinus of Valsalva that extended into the RVOT. An aortogram showed a fistulous connection between the aneurysm and the pulmonary artery, which led to the diagnosis of a ruptured aneurysm of the sinus of Valsalva. There was a pressure gradient of 40 mm Hg between the right ventricle and the pulmonary artery. Magnetic resonance imaging angiography and computed tomography confirmed that the aneurysm extended into the RVOT, crossed over the pulmonary valve, and protruded into the pulmonary artery (Figure 1 ).
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7 mm in diameter) that was opening into the pulmonary artery (Figure 2
). The wall from the right coronary sinus to the neck of the aneurysm was calcified. The aneurysm was removed through a pulmonary incision. Because of the calcified wall, we could not resect all of the aneurysm and left some of it in the right ventricle. We closed the defect of the right sinus of Valsalva with an expanded polytetrafluoroethylene patch through the pulmonary incision. The patient was easily weaned from cardiopulmonary bypass. The postoperative course was good. On postoperative echocardiography, no residual shunt was detected.
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Sinus of Valsalva aneurysms are rare. In most cases, the aneurysm arises from the right coronary sinus, which is normally adjacent to the RVOT. The aneurysm can rupture any cardiac chamber, most commonly into the right ventricle and occasionally into the right atrium. Rupture into the pulmonary artery is rare, and only 4 cases have been reported in the medical literature.1-4
In addition, 1 additional case involved an unruptured aneurysm of the sinus of Valsalva into the pulmonary artery.5 In the presented case, an aneurysm originated from the right sinus of Valsalva and protruded into the pulmonary artery. The aneurysm extended from the right ventricle passing through the pulmonary valve and caused a pressure gradient between the right ventricle and the pulmonary artery.
Aortography showed an aortopulmonary fistula but did not correctly reveal that the aneurysm had passed through the pulmonary valve. Magnetic resonance imaging angiography and computed tomography confirmed the diagnosis.
Other characteristics of this case are that the onset of heart failure was not sudden and that the patient did not have any other cardiac defects, such as a ventricular septal defect. These clinical features suggested that the patient's heart murmur from childhood was caused by a chronic fistula between the aneurysm and the pulmonary artery. In cases of ruptured sinus of Valsalva aneurysm, it is common to have a sudden onset of symptoms. In the presented case, his symptoms became insidiously worse.
Preoperative aortic regurgitation was slight in this case and did not worsen postoperatively. However, because of the calcified deformity of the remains of the sinus of Valsalva, we are concerned about the progression of aortic regurgitation and the patient must be kept under close long-term observation.
References
This article has been cited by other articles:
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  H.-W. Guo, X.-G. Sun, J.-P. Xu, H. Xiong, X.-Q. Wang, W.-J. Su, Y. Lin, and S.-S. Hu A new and simple classification for the non-coronary sinus of Valsalva aneurysm Eur J Cardiothorac Surg, November 1, 2011; 40(5): 1047 - 1051. [Abstract] [Full Text] [PDF]
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 Y.-L. Liu, A.-J. Liu, F. Ling, D. Wang, Y.-B. Zhu, Q. Wang, and X.-D. Lv Risk Factors for Preoperative and Postoperative Progression of Aortic Regurgitation in Congenital Ruptured Sinus of Valsalva Aneurysm Ann. Thorac. Surg., February 1, 2011; 91(2): 542 - 548. [Abstract] [Full Text] [PDF]
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