Sinus of Valsalva aneurysms and application of surgical science to their repair

Calcified unruptured sinus of Valsalva aneurysm in a child

Sinus of Valsalva aneurysms (SOVAs) might be congenital or acquired in origin. They might present as a rupture or as a consequence of compression on adjacent structures. The treatment of such aneurysms in adults is well documented. Calcified unruptured SOVAs are rarer and their management is not well elucidated, more so in the pediatric population. We present the management and outcome of such a case.

Surgical correction of ruptured aneurysms of the sinus of Valsalva using on-pump beating-heart technique

BACKGROUND

Rupture of aneurysms of the sinus of Valsalva results in abrupt onset of congestive heart failure. On-pump beating-heart surgery may reduce cardiac impairment by maintaining coronary blood flow and avoiding cardioplegia. Herein, we report the operative correction of thirty-one patients of ruptured aneurysms of the sinus of Valsalva, using the on-pump beating-heart technique.

METHODS

Thirty-one patients with ruptured aneurysms of the sinus of Valsalva underwent operative corrections using the on-pump beating-heart technique. In patients with fistula diameter less than 1 cm and no aortic regurgitation, the aorta was unclamped throughout cardiopulmonary bypass(CPB) while receiving antegrade heart perfusion. In remainder of patients, retrograde perfusion was used.

RESULTS

After intracardiac manipulation was complete and the nasopharyngeal temperature was raised to 36-37 degrees C, the patients were smoothly weaned off CPB. There were no early or late postoperative deaths. All patients were in New York Heart Association functional class I at follow-up (range, 0.5-1 year). Mild-to-moderate aortic valve regurgitation was observed in one patient. No recurrence of the left-to-right shunt from ruptured aneurysms of the sinus of Valsalva was observed.

CONCLUSIONS

Beating heart on pump allows adequate examination of the aortic lesion under near-physiologic conditions, allows decrease in ischemia-reperfusion injury and potentially decreases the risk of serious or fatal rhythm disturbances. On-pump beating-heart technique for repair of ruptured aneurysm of sinus of Valsalva is feasible and promising. Antegrade heart perfusion is suitable for patients with a fistula diameter <1 cm and no aortic regurgitation, and retrograde perfusion is suitable for the others.

Percutaneous closure of a ruptured sinus of Valsalva aneurysm using the Amplatzer Duct Occluder

Sinus of Valsalva aneurysms are rare congenital anomalies. When they rupture, they can lead to the development of biventricular failure as a result of systemic-pulmonary shunting. Surgical repair has been the traditional treatment for these aneurysms. We present a case of a 54 year old man in whom a ruptured sinus of Valsalva aneurysm was successfully closed using a catheter-based approach with the Amplatzer Duct Occluder.

Sinus of Valsalva aneurysm or fistula: management and outcome

BACKGROUND

Few large or long-term series exist regarding the management of patients with sinus of Valsalva aneurysms or fistulas (SVAFs).

METHODS

Between 1956 and 1997, 129 patients presented with a ruptured (64 cases; 49.6%) or nonruptured (65 cases; 50.4%) SVAF. The patients included 88 men and 41 women, with a mean age of 39.1 years. Associated findings included a history of endocarditis (42 cases; 32.6%), a bicuspid aortic valve (21 cases; 16.3%), a ventricular septal defect (15 cases; 11.6%), and Marfan's syndrome (12 cases; 9.3%). Operative procedures included simple plication (61 cases; 47.3%), patch repair (52 cases; 40.3%), aortic root replacement (16 cases; 12.4%), and aortic valve replacement/repair (75 cases; 58.1%).

RESULTS

There were five in-hospital deaths (3.9%): four due to preexisting sepsis and endocarditis and one that followed dehiscence of the repair in a patient with Marfan's syndrome. Two patients (1.6%) had strokes during the early postoperative period. The survivors were followed up for 661.1 patient-years (5.3 years/patient). The following late complications occurred: prosthetic valve malfunction (5 cases; 3.9%), prosthetic valve endocarditis (3 cases; 2.3%), SVAF recurrence (2 cases; 1.6%), thrombosis (1 case; 0.8%), and anticoagulation-related bleeding (1 case; 0.8%).

CONCLUSIONS

Resection and repair of SVAF entails an acceptably low operative risk and yields long-term freedom from symptoms. Early, aggressive treatment is recommended to prevent endocarditis or lesional enlargement, which causes worse symptoms and necessitates more extensive repair.