Ruptured sinus of valsalva aneurysm: early recurrence and fate of the aortic valve

Ruptured Sinus of Valsalva Aneurysm: Transcatheter Closure Through Retrograde Approach

The ruptured sinus of Valsalva aneurysm (RSOV), a rare but well-recognized clinical entity, is invariably a form of left-to-right shunt due to rupture into right-sided chambers. It causes profound hemodynamic effects, especially when the rupture is acute. Like most other left-to-right shunts, it was only a matter of time before this rare defect also became amenable to transcatheter closure (TCC). Since the first report of TCC of RSOV by Cullen et al. in 1994 using the Rashkind umbrella, in recent times, there has been a spate of case reports, brief communications, and interesting case presentations at interventional meetings using the much more user-friendly and effective devices. We report a case of a 59-year-old female diagnosed with RSOV (noncoronary cusp to right atrium) treated with device closure by using a vascular plug through a retrograde approach without resorting to the usual antegrade technique involving the formation of an arteriovenous loop.

Percutaneous Closure of a Ruptured Sinus of Valsalva Aneurysm under Transesophageal Echocardiography Guidance

•SOVA is a rare cardiac anomaly. •Ruptured SOVA carries a high mortality rate. •SOVA often coexists with other congenital lesions, most commonly VSD and bicuspid AV. •Ruptured SOVA needs repair; percutaneous repair is a safe alternative to surgery. •Echo plays a vital role in both diagnosing SOVA and guiding percutaneous closure.

Sinus of valsalva aneurysm: A single institutional experience with 216 patients over 30 years

BACKGROUND

Sinus of valsalva aneurysm (SVA) with rupture is a rare cardiac anomaly which can be congenital or acquired with reported incidence of 0.46%-3.57% among Asians population.

AIM OF THE STUDY

The aim of this study is to analyze 30 years of single institutional surgical experience in management of 216 cases with SVAs from 1992 till date.

METHODS

Age group was from 6 to 64 years (mean: 32.5 ± 11 years) with male to female ratio of 2.2:1. The aneurysms originated from right coronary sinus in 181 cases (83.79%), noncoronary sinus in 35 cases (15.74%) and ruptured into the right ventricle in 149 cases (68.98%), right atrium in 59 cases (27.31%). Bicameral approach was used in majority of the cases (n = 213, 98.61%). Aneurysms were repaired using Dacron patch in 173 cases (80.09%) and direct closure in 43 cases (19.9%). Associated ventricular septal defect was closed with Dacron patch in 123 cases (56.94%). Aortic valve was replaced in 21 cases (9.72%) and aortic valve repair was performed in 14 cases (6.48%) for associated Aortic regurgitation.

RESULTS

There were no perioperative hospital deaths. Follow-up was available in 204 patients (94.44%) ranging from 2 to 26 years (mean: 10 ± 5.6 years). Two deaths (0.92%) occurred during the postoperative follow-up period. The actual survival was 99.5% at 1 year, 99% at 5 and 10 years.

CONCLUSION

Long term results of surgically repaired SVAs are good with low morbidity (3.24%) and mortality (0.92%) even when associated with major cardiac anomalies. Aortic valve repair and replacement both are equally feasible alternatives for management of moderate to severe aortic regurgitation with associated merits and demerits.

Sinus of Valsalva aneurysm: Defining the optimal approach

Sinus of Valsalva aneurysm (SVA) is relatively rare, especially in Western countries, and reports on long-term results after surgical SVA repair in a sizable patient cohort are scarce. In this issue of the Journal of Cardiac Surgery, Chaganti and colleagues publish their surgical experience over the past 30 years in 216 patients with SVA. SVAs were closed via a dual approach, with (1) patch closure (80%) or direct closure (20%) of the base of the fistula through aortotomy and (2) direct closure of the ruptured tip through the chamber of rupture. Aortic valve replacement (9.7%) or repair (6.5%) was performed for moderate to severe aortic regurgitation (AR). There was no hospital mortality. During a mean follow-up of 10 years, no patient had residual/recurrent shunting. The actual survival at 10 years was 99%, with only two deaths. Freedom from moderate or severe AR was 98.5% at 10 years. Early and long-term results after surgical repair of SVA were excellent in their 216 patients with a mean follow-up of 10 years. Their dual approach for SVA was effective in preventing residual/recurrent shunting. The need for AVR in 10% of the patients speaks to the importance of follow-up. The current report provides strong support for surgical repair being the preferred management for SVA.

Risk Factors for Aortic Regurgitation Progression After Repair of Sinus of Valsalva Aneurysm

BACKGROUND

The main treatment for a ruptured sinus of Valsalva aneurysm (SVA) is surgical repair. Postoperative progression of aortic regurgitation (AR) following SVA repair increases the risk of reoperation, which decreases the long-term survival. Thus, identifying the risk factors for postoperative AR progression is of great significance.

METHODS

Adult patients who were diagnosed with ruptured SVA and underwent surgical repair at the current centre were reviewed. Necessary data in the institutional database were extracted. The perioperative and follow-up assessments of the aortic valve by transthoracic echocardiography were also obtained. The aortic regurgitation progression was grouped into three categories: newly developing, recurrence, and worsening. Sixteen (16) variables were screened to identify potential risk factors by univariate logistic regression analysis or Chi-squared test. Variables with p-values <0.1 were further analysed by multivariate logistic regression models to find independent risk factors.

RESULTS

A total of 198 consecutive patients from June 2006 to January 2018 were included. The overall incidence of postoperative AR progression was 19.2% (38 of 198). After the univariate analysis, SVA originating from the right coronary sinus, coexisting with ventricular septal defect, larger diameter of aortic annulus, and larger cardiothoracic ratio were screened as potential risk factors. Multivariate analysis indicated that coexisting with a ventricular septal defect (VSD) (OR, 2.82; 95% CI, 1.217-6.532; p=0.016) and larger cardiothoracic ratio (OR, 1.061; 95% CI, 1.001-1.124; p=0.047) were independent risk factors for postoperative AR progression.

CONCLUSIONS

To prevent postoperative AR progression after surgical repair, more careful inspection and appropriate surgical techniques are necessary for patients coexisting with VSD or with a larger cardiothoracic ratio.

Ruptured sinus of Valsalva aneurysms - our surgical experience of 7 years

Introduction

Aneurysms of sinuses of Valsalva are rare aortic anomalies having an incidence of 1.4–4.94% in the Asian population. Spontaneous rupture is the most common complication and ruptured aneurysms usually present with congestive cardiac failure.

Aim

Our study was aimed at evaluating the clinical profile of patients with ruptured sinus of Valsalva aneurysms (RSOVA) and their distribution, the surgical management and post-operative course.

Material and methods

We retrospectively identified 21 patients who presented to us with RSOVA over a period of 7 years and underwent surgery for the same.

Results

RSOVA was more common in young males. Most cases involved the right coronary sinus (RCS) followed by the non-coronary sinus (NCS). The site of rupture was mostly the right ventricular outflow tract or the right atrium. All patients had a relatively asymptomatic post-operative course in the ward. On follow-up, most of the patients were symptom free.

Conclusions

Surgery on cardiopulmonary bypass with moderate hypothermia with excision of windsock deformity and patching of the rupture site is a safe method of treating ruptured sinus of Valsalva aneurysms. Patients need to be followed up regularly to monitor for the development of aortic regurgitation.

Surgical repair of ruptured sinus of Valsalva aneurysm: 13-year single center experience

BACKGROUND AND AIM

Untreated ruptured sinus of Valsalva aneurysms ultimately develop into heart failure, thereby affecting patients' survival. We retrospectively analyzed our 13-year experience of the surgical repair for ruptured sinus of Valsalva aneurysm to study the optimal surgical strategy, operative risk and long-term surgical outcome.

METHODS

Twenty-six patients underwent surgical repair of ruptured sinus of Valsalva aneurysm from January 2008 to February 2020. Follow-up data were obtained from the outpatient department records and telephone calls.

RESULTS

Patch closure of ruptured sinus of Valsalva aneurysm was done in all the 26 patients, most often through the transaortic (69%) and dual-chamber approach (23%). Aortic valve repair was done in one patient while seven patients underwent aortic valve replacement for associated significant aortic regurgitation. There was one in-hospital mortality because of noncardiac cause. The median duration of postoperative hospital stay was 8 days (range, 6-11 days). Follow-up data were available for 89% (23/26) patients. The mean follow-up period was 69 ± 43 months (range, 7-147 months). All survivors were in New York Heart Association functional Class I or II. There was no late death. One patient required rehospitalization for recurrent ruptured sinus of Valsalva aneurysm. There was no recurrent or new-onset significant aortic regurgitation and prosthesis-related complications in late follow-up.

CONCLUSION

Surgical repair for ruptured sinus of Valsalva aneurysm carries an acceptable low operative risk and excellent long-term outcome. Though high-risk population, an early diagnosis and optimal surgical approach can prevent worsening of symptoms and consequent heart failure.

Sinus of Valsalva Aneurysms: A Review with Perioperative Considerations

The sinuses of Valsalva are outpouchings in the aortic root just distal to the aortic valve that serve several physiologic functions. Aneurysm of this segment of the aorta is quite rare and infrequently encountered in clinical practice. Due to the rarity of sinus of Valsalva aneurysms, there is a lack of controlled trials and most of the literature consists of case reports and series. Here, the authors review the currently available literature to discuss the anatomy and normal function of the aortic root, as well as disease pathology and diagnostic imaging considerations. Using reported cases, the authors also will discuss considerations for cardiac anesthesiologists in the perioperative period.

Right ventricular outflow tract obstruction caused by sinus of Valsalva aneurysm

Right ventricular outflow tract (RVOT) obstruction caused by sinus of Valsalva aneurysm is a rare observation. We describe a successful case of valve-sparing root replacement using reimplantation technique for RVOT obstruction by a large right coronary sinus of Valsalva aneurysm in a 76-year-old man. In the pathological examination, the elastic fibers of the medial layer were defective not only in the wall of the aneurysmal Valsalva sinus but also in the remaining two sinus walls. Our experience illustrated that valve-sparing root replacement can be an effective procedure in such a case.

Surgical repair of a ruptured congenital sinus of Valsalva aneurysm: 10-year experience with 286 cases

OBJECTIVES

Surgical intervention is the main treatment for a ruptured congenital sinus of Valsalva aneurysm (SVA). However, reports on the surgical experience are scarce. We retrospectively analysed the cases of our centre to summarize our 10-year experience.

METHODS

A total of 286 patients who were diagnosed with a congenital ruptured SVA and underwent surgical repair between 2007 and 2016 were identified for the analysis. Follow-up data (mean ± standard deviation: 49.6 ± 34.9 months) were obtained from outpatient department records and telephone calls.

RESULTS

The SVAs originated from the right coronary sinus (79.7%), the non-coronary sinus (19.6%) and the left coronary sinus (0.7%) but ruptured into the right ventricle (58.4%) and the right atrium (41.3%). The most commonly associated deformities were a ventricular septal defect (46.3%), aortic valve regurgitation (33.2%) and tricuspid regurgitation (20.3%). The SVA defect was closed by direct suturing (9.1%) or patching (90.9%) through an incision in the cardiac chamber involved or a transaortic approach. The mean postoperative hospital stay duration was 7.2 days, and 98.6% of the patients were discharged in New York Heart Association functional class I or II. The incidence rate of short-term complications was 5.7%. There were 4 late deaths, and 9 patients required rehospitalization due to surgery-related events. The estimated 10-year survival rate was greater than 90% according to the Kaplan-Meier survival curve.

CONCLUSIONS

Surgical repair is an effective and safe treatment for a ruptured SVA. The majority of patients who undergo surgical repair can survive for a long time.

Rupture of sinus of valsalva - A 15 years single institutional retrospective review: Preoperative heart failure has an impact on post operative outcome?

Background

We reviewed our experience with ruptured sinus of Valsalva aneurysms (RSOV) to determine a correlation with preexisting heart failure (HF) and coexisting cardiac lesions (aortic regurgitation [AR] and ventricular septal defect [VSD]) to postoperative left ventricular (LV) dysfunction and postoperative outcomes.

Materials and Methods

Retrospective review of RSOV cases over 15 years showed that RSOV repair was done in 87 patients. We looked for patients who presented with HF and patients having AR and/or VSDs. Statistical analysis was done to see if the coexisting lesions and preoperative HF were associated with postoperative LV dysfunction. Chi-square test was used on contingency table for statistical analysis. Complications in the postoperative period and prolonged Intensive Care Unit stay were noted.

Results

17% (15/87) presented with HF. Fifty-two patients had moderate to severe AR and 50 patients had VSD. Seventeen patients had postoperative LV dysfunction. The correlation of preoperative HF and coexisting lesions with postoperative LV dysfunction was not statistically significant. Two patients underwent redo surgery for residual RSOV and AR. Two patients had arrhythmias. One patient had cerebrovascular accident. No mortality was seen in the study.

Conclusion

Preoperative HF and the presence of VSD and/or AR have no statistical significant correlation with postoperative LV dysfunction. As the outcome of RSOV repair is good, all patients need to undergo early repair to avoid complications.

Ruptured Sinus of Valsalva Aneurysm and Gerbode Defects: Patient and Procedural Selection: the Key to Optimising Outcomes

PURPOSE OF REVIEW

In this review, we reflect on the historical background, clinical features and imaging techniques used to assess Gerbode defects and sinus of Valsalva aneurysms. We aim to review the evolution of treatment strategies and the progression towards less invasive management for these conditions.

RECENT FINDINGS

While transthoracic echocardiography is often diagnostic, transesophageal echocardiography (2D and 3D) has improved our understanding of these defects and allowed us to more accurately define their anatomy. Cardiac MRI provides improved assessment of the physiological impact of defects by quantifying shunt volume. Transcatheter techniques are currently vying with surgery as the mainstay of treatment. New insights are being discovered regarding diagnostic modalities and treatment pathways. Defining criteria for patient selection for catheter or surgical therapy is essential when deciding on the optimum intervention for the individual patient.

Short-Term Results of Sinus of Valsalva Aneurysm Repair

BACKGROUND

We retrospectively analyzed 65 patients who underwent surgical repair of sinus of Valsalva aneurysm over the last 27 years.

METHODS

From January 1, 1988, to October 1, 2015, a total of 65 patients with sinus of Valsalva aneurysm underwent surgical repair in our hospital. There were 41 males (63%) and 24 females (37%), and their age ranged from 5 to 50 years (mean 23 ± 10 years, median 21 years). Out of the 65 patients, 45 (69%) had ruptured sinus of Valsalva aneurysm, 46 (70%) had a ventricular septal defect, and 22 (34%) had aortic valve insufficiency. The ruptured sinus of Valsalva was repaired with patch in 12 cases and direct suturing in 33 cases. The aortic valve was replaced in five patients and the aortic root was replaced in five patients.

RESULTS

Sixty patients (92%) survived the 30-day operative interval. At one year follow-up, only two patients had complications: infective endocarditis and sepsis, which lead to septic shock (n = 1) and paraprosthetic leakage and mitral valve regurgitation (n = 1). All the other patients were well and in New York Heart Association functional class I or II.

CONCLUSION

In this relatively high-risk population, repair of SVA can be achieved with satisfactory early results.

Incidental Finding of an Aorto-Right Atrial Fistula in a Patient Undergoing Repair of a Sinus of Valsalva Aneurysm

A sinus of Valsalva aneurysm is a rare malformation of the aortic root that can fistulize to another cardiac structure such as the right atrium. Although transthoracic echocardiography and computed tomography angiography have demonstrated utility for the diagnosis of a sinus of Valsalva-to-right atrial fistula, there are few cases where a misdiagnosis may occur. Intraoperative transesophageal echocardiography may be an essential imaging tool for the diagnosis and management of incidental findings such as a sinus of Valsalva-to-right atrial fistula during cardiac surgery and should be used routinely.

Sinus of Valsalva Aneurysm in a Patient With Mosaic Trisomy 13: Case Report and Brief Review of the Literature

This report describes a unique case involving an obese 16-year-old boy with a mosaic form of trisomy 13 and no previous cardiac history who presented with a new murmur, hypertension, pleural effusions, and congestive heart failure in the context of sore throat and fever. Evaluation revealed a diagnosis of ruptured noncoronary sinus of Valsalva (SOV) aneurysm. The diagnosis and surgical management of a ruptured noncoronary SOV aneurysm in a pediatric patient are briefly outlined. An SOV aneurysm is an anatomic dilation of one of the sinuses of the aortic root. Aneurysmal dilation occurs more commonly in the right aortic sinus (70%-80%), compared to the noncoronary sinus (23%-25%), and more rarely the left coronary sinus (5%). Rupture of these aneurysms has been reported to be both spontaneous and secondary to physical exertion, hypertension, or trauma. Signs of rupture include a continuous murmur, patients may present with chest pain or with symptoms of acute congestive heart failure. Diagnosis, in this case, was made by transthoracic echocardiography with careful interpretation of color Doppler images.

Comparison of reported outcomes with percutaneous versus surgical closure of ruptured sinus of Valsalva aneurysm

Sinus of Valsalva aneurysm is a rare cardiac malformation that stems from incomplete fusion of the aortic media and the aortic valve annulus, a weakness that may result in rupture of the sinus, large left-to-right shunt, and severe congestive heart failure. Historically, this lesion has been repaired surgically, but percutaneous closure (PC) has emerged as a therapeutic intervention over the last 20 years. We review and contrast 34 studies detailing the PC approach with 16 studies on surgical closure (SC), together comprising a total of 877 patients who were treated for ruptured sinus of Valsalva aneurysm from 1956 to 2014. Both groups had similar sites of rupture, age distribution, and clinical symptoms at presentation. Selection bias ultimately prohibits a direct comparison between the 2 groups as patients who underwent SC often had worse aortic regurgitation and more complex associated lesions, including endocarditis, bicuspid aortic valve, tunnel-type fistulous connections, larger defect size, and multiple site of rupture. In conclusion, although SC is indicated and reserved for these more complicated patients, our review of previously published reports reveals that PC in patients who are too ill to undergo bypass, with mild or no aortic regurgitation and simple associated defects (muscular ventricular septal defects, secundum atrial septal defect, small patent ductus arteriosus), can be safe, effective, and practical.

Bad company: supracristal VSD presenting with ruptured sinus of valsalva aneurysm. a case presentation with echocardiographic depiction and an analysis of contemporary literature

Supracristal ventricular septal defect (SCVSD), a defect of the infundibular portion of the interventricular septum just below the right aortic cusp, occurs more frequently in Eastern Asian populations. SCVSD may be complicated by right sinus of Valsalva aneurysm (SoVA). We present the case of a 26-year-old male of Korean descent with a history of a childhood murmur who was referred to our institution for progressive heart failure symptoms. He was diagnosed with SCVSD and ruptured right SoVA based on history, physical exam, and echocardiography including three-dimensional transesophageal echocardiography with reconstructed surgical views. The patient underwent SCVSD closure, SoVA excision, and valve-sparing aortic root replacement. We reviewed the echocardiography literature regarding SCVSD and SoVA, and analyzed contemporary literature of SoVA and its relationship with SCVSD. We conclude that a higher prevalence of ruptured SoVA in Eastern Asians is likely related to a higher prevalence of underlying SCVSD in this population.

Contained rupture of the sinus of valsalva associated with infective endocarditis and untreated congenital ventricular septal defect

Isolated sinus of Valsalva (SV) aneurysm is a rare condition that may arise in patients with congenital ventricular septal defects (VSD). Small VSDs are often left untreated because of high rate of spontaneous closure. However, complications such as aortic regurgitation and infective endocarditis may occur as complications of small VSDs. We present the case of a 19-year-old man with a history of VSD, who presented with Staphylococcus aureus endocarditis and a contained rupture of the SV into the right ventricle, which was successfully treated. In the light of this case, we believe that even small VSDs should be assessed regularly and treated before such drastic complications occur.

Perforated Sinus of Valsalva (PSOV) aneurysm closure with a muscular VSD occluder

We report a case of a Perforated Sinus of Valsalva Aneurysm (PSOV) closure using an Amplatzer muscular ventricular septal defect occluder (mVSD) device and describe a novel and potentially safer way for defect sizing. A literature review of the endovascular treatment of this disease is presented.

Modified Sakakibara classification system for ruptured sinus of Valsalva aneurysm

OBJECTIVE

To introduce a modified Sakakibara classification system for a ruptured sinus of Valsalva aneurysm.

METHODS

From February 1, 2006, to January 31, 2012, surgical repair was performed on 159 patients with a ruptured sinus of Valsalva aneurysm at Fu Wai Hospital. Of the 159 patients, 105 were men and 54 were women, with a mean age of 33.4 ± 10.7 years. The patients were divided into 5 types according to the site of the ruptured sinus of Valsalva aneurysm rupture. The 5 types were as follows: type I, rupture into the right ventricle just beneath the pulmonary valve (n = 66); type II, rupture into or just beneath the crista supraventricularis of the right ventricle (n = 17); type III, rupture into the right atrium (type IIIa, n = 21) or right ventricle (type IIIv, n = 6) near or at the tricuspid annulus; type IV, rupture into the right atrium (n = 46); and type V, other rare conditions, such as rupture into the left atrium, left ventricle, or pulmonary artery (n = 3).

RESULTS

Repair of ruptured sinus of Valsalva aneurysm through aortotomy was used in 100% of those with type V and 50% of those with type IIIv. In most patients with types I, II, and IV, repair was achieved through the cardiac chamber of the fistula exit (71.2%, 64.7%, and 69.6%, respectively). Both routes of repair were used in 76.2% of patients with type IIIa. No early and late deaths occurred. The aortic valve was replaced in 33 patients. One patient (type IV) underwent reoperation for a residual shunt during the follow-up period.

CONCLUSIONS

The modified classification system for ruptured sinus of Valsalva aneurysm is simple and practical for clinical use.

Surgery for ruptured sinus of Valsalva aneurysm: 25-year experience with 55 patients

OBJECTIVES

Different surgical strategies have been evolved for the surgical treatment of ruptured sinus of Valsalva aneurysm (RSVA) from simple primary closure to patching of the rupture site by a dual chamber approach. We reviewed our 25-year experience and current literature regarding the efficacy of different surgical approaches.

METHODS

A retrospective review identified 55 patients who underwent RSVA repair between 1985 and 2011. The mean age was 30.9 ± 12.1 years. The RSVA originated from the right coronary sinus in 43 patients (78.2%), from the non-coronary sinus in 11 (20.0%) and from the left in 1. Rupture into the right ventricle was the most common result (n = 38). Dual-chamber exposure (the involved chamber and aorta) was used in 67.3% of the patients and isolated trans-aortic approach was used in 32.7%. RSVA was repaired with either a patch (n = 43) or direct sutures (n = 12), whereas the aortic valve was replaced in eight patients among the last group.

RESULTS

The hospital mortality rate was 3.6%. The follow-up was available in 94.3% (50 patients) of survivors ranging from 1 month to 25 years (mean 15.3 ± 4.1 years). There were five late deaths. Recurrence of the fistula was seen in two primarily repaired (two of four patients) and none of the patched-closed patients. Actual survival was 93.4 ± 3.7% at 10 years and 87.1 ± 5.6% at 15 years. Freedom from reoperations was 81.6 ± 6.1% at 15 years.

CONCLUSIONS

Surgical treatment for RSVA carries an acceptably low operative risk and long-term freedom from death and reoperation. Surgical approach must be chosen according to the ruptured chamber and associated lesions. Patch repair of RSVA must be preferred.

Silent rupture of sinus of Valsalva aneurysm: a refutation of the Okham's razor principle

Aneurysm of the sinus of Valsalva is an uncommon congenital lesion rarely reported in children. Unruptured aneurysms commonly go undiagnosed until a rupture has occurred. Usually, ruptured sinus of Valsalva presents with cardiac failure. There may be a history of trauma or infective endocarditis preceding the rupture. Asymptomatic paediatric presentation of ruptured sinus of Valsalva is rare. We discuss the cases of two children who presented with a murmur and were diagnosed with ruptured sinus of Valsalva. This unusual presentation in children highlights the importance of careful routine physical examinations and the evaluation of new murmurs. The Okham's razor principle states that "when you hear hoofbeats - think horses not zebras". Sometimes, it is important to think beyond the usual in medicine, to avoid missing lesions that, if left untreated, could lead to adverse outcomes.

Ruptured sinus of Valsalva aneurysm: 10-year Indian surgical experience

Sinus of Valsalva aneurysm is a rare anomaly with a higher incidence in Eastern than Western populations. Recent improvements in diagnostic techniques have resulted in more patients undergoing surgical repair. Uncorrected, the intracardiac shunts and frequently associated cardiac lesions cause a preventable deterioration in heart function. We retrospectively analyzed the data of 33 patients who underwent repair of ruptured sinus of Valsalva aneurysm from May 2000 to January 2010. The aneurysms originated from the right coronary sinus in 24 patients and from the noncoronary sinus in 9, and ruptured into the right ventricle in 21, right atrium in 10, and left ventricle in 2. Operative procedures included simple plication (1), patch repair (32), and aortic valve replacement (10). There were 3 early deaths. The 30 survivors were followed up for 5.4 ± 2.6 years; all had an improvement in functional class, with superior results in those with no aortic regurgitation. Surgical treatment of ruptured sinus of Valsalva aneurysm has an acceptably low operative risk and good long-term symptom-freedom survival. An early aggressive approach is recommended to prevent worsening symptoms and more extensive disease.

Emergency surgery for ruptured sinus of Valsalva aneurysms

OBJECTIVES

A ruptured sinus of Valsalva aneurysm is a very rare cardiac anomaly. Successful repair of these aneurysms was first described in the late 1950s. Several approaches for repair, through the aortic root or the chamber into which the aneurysm ruptures or a combination of both, have been described. We present our experience with emergency surgical repair of ruptured sinus of Valsalva aneurysms and our current surgical policy.

DESIGN

A review of the St. Antonius Hospital database from January 1972 to December 2010 identified a total of 16 patients. A retrospective review of their medical records and telephonic follow-up was performed.

RESULTS

Fifteen patients (13 male, three female) aged 46 ? 13 years were operated. The ruptured aneurysm arose from the right coronary (63%) and non-coronary sinus (37%) and ruptured into the right ventricle (67%) and into right atrium (33%). Primary suture closure was done in six patients and patch closure was performed in the remaining 10 patients. No intra-operative death occurred. Long-term follow-up identified one recurrent fistula from right coronary sinus to right atrium 28 years after primary suture closure.

CONCLUSIONS

We performed prompt surgical repair of the ruptured sinus of Valsalva aneurysm preferably with a patch.

An Unusual Case of Sinus of Valsalva Aneurysm in a GUCH Patient: An Unusual Side of the Aorto-Cardiac Fistula

Sinus of Valsalva aneurysm can be congenital or acquired. The major complication is rupture: this can represent an evolution or an abrupt event. In case of rupture or of large aneurysm, a surgical approach is justified. We report a case of ruptured sinus of Valsalva aneurysm in a seventeen years old girl, who had underwent surgical correction of Fallot tetralogy. As soon as the rupture of sinus of Valsalva aneurysm is suspected, echocardiographic examination is the easiest and most straightforward tool to make a correct diagnosis.

Valsalva sinus aneurysms: findings at CT and MR imaging

Aneurysms of the Valsalva sinus (aortic sinus) can be congenital or acquired and are rare. They are more common among men than women and among Asians than other ethnic groups. Nonruptured aneurysms may be asymptomatic and incidentally discovered, or they may be symptomatic and manifest acutely with mass effect on adjacent cardiac structures. Ruptured Valsalva sinus aneurysms result in an aortocardiac shunt and may manifest as insidiously progressive congestive heart failure, severe acute chest pain with dyspnea, or, in extreme cases, cardiac arrest. Although both ruptured and nonruptured Valsalva sinus aneurysms may have potentially fatal complications, after treatment the prognosis is excellent. Thus, prompt and accurate diagnosis is critical. Most Valsalva sinus aneurysms are diagnosed on the basis of echocardiography, with or without angiography. However, both electrocardiographically gated computed tomography and magnetic resonance (MR) imaging can provide excellent anatomic depiction, and MR imaging can provide valuable functional information.

Geometric reconstruction of the sinus of Valsalva: utilization of the porcine aortic root

Surgical repair of ruptured sinus of Valsalva aneurysm can be challenging, although it has been reported that mortality and morbidity is low. Distortion of sinus of Valsalva geometry can cause aortic valve regurgitation immediately or progressively after surgery. Maintenance of the appropriate geometry of sinus of Valsalva after resection of the aneurysm is critical in preserving the native aortic valve and its competency. Successful reconstruction with various patch materials such as Dacron patches (DuPont, Wilmington, DE) or pericardial patches has been reported. Nevertheless, the size and shape of patches used had to be created impromptu by surgeons without reliable methodology of reproducing the precise shape of the naturally occurring sinus of Valsalva. Herein, we report a successful repair of sinus of Valsalva aneurysm by utilizing a porcine sinus of Valsalva from a commercially available Freestyle valve (Medtronic Inc, Minneapolis, MN). We believe that this is a previously unreported technique.

Ruptured right sinus of Valsalva aneurysm with bicuspid aortic valve

The sinus of Valsalva aneurysm is a relatively rare condition that may be congenital or acquired. We present a case of a young man who was admitted to the emergency department with acute dyspnoea whilst playing football. After investigation, the diagnosis of a ruptured right sinus of Valsalva aneurysm into the right atrium was made. The patient also had a bicuspid aortic valve. Percutaneous approach to close the fistula was unsuccessful and the patient underwent surgical closure of the fistula with replacement of his bicuspid aortic valve.

Surgery for Sinus of Valsalva Aneurysm: 27-Year Experience with 100 Patients

Sinus of Valsalva aneurysm is a rare anomaly. This study was designed to assess the long-term outcome of surgical repair of sinus of Valsalva aneurysm and factors influencing the prognosis. From August 1980 to August sinus of Valsalva aneurysm repair. Ventricular septal defect (42) and aortic regurgitation (34) were the most frequent coexisting anomalies. An approach via the involved chamber was used in 60 patients, aortotomy in 5, and a combined approach in 35. Either direct (43) or patch (57) closure was used to repair the defect. Aortic valve replacement was required in 14 patients, and 8 needed valvuloplasty. Eighty patients were followed up for 15.6 ± 3.9 years. There were 3 hospital deaths and 2 late deaths. New York Heart Association functional class improved significantly after surgery. Actuarial survival was 94% at 10 years, and 90% at 15 years. Surgical treatment of sinus of Valsalva aneurysm is safe and effective, but late progressive aortic regurgitation is still a risk during long-term follow-up, and early aggressive measures are recommended.

Severe Aortic Regurgitation After Repair of Ruptured Sinus of Valsalva Aneurysm: The Role of Transesophageal Echocardiography

We report a 27-year-old woman who presented with worsening exertional dyspnea and palpitation. Transthoracic echocardiography showed ventricular septal defect, with left-to-right shunting and mild aortic regurgitation detected. Cardiac catheterization was performed that revealed sinus of Valsalva aneurysm with rupture into the right ventricle. Transesophageal echocardiography (TEE) confirmed a rupture of sinus of Valsalva aneurysm and ventricular septal defect. The patient underwent elective surgical repair of the ruptured sinus and intraoperative TEE demonstrated severe aortic regurgitation after repair and mechanical prosthetic valve was implanted. This case illustrates that TEE frequently establishes the diagnosis and provides more information concerning additional cardiac lesions in a patient with ruptured sinus of Valsalva aneurysm. Aortic regurgitation should be evaluated after repair of rupture of sinus of Valsalva by TEE.

Associated replacement of ascending aorta, aortic valve, and noncoronary sinus of Valsalva

A simple technique utilized when replacement of the ascending aorta has to be associated with replacement of the aortic valve and the sole noncoronary sinus of Valsalva (vs. total root replacement) is presented. It offers the advantage to secure stable hemostasis in an area where surgical exposure may be difficult to achieve off-pump. For its easy reproducibility, this procedure might contribute to a more radical resection of diseased tissue thus limiting risk of further dilatation, rupture, and need for reoperation.

Surgical Repair of Sinus of Valsalva Aneurysm in Asian Patients

BACKGROUND

Sinus of Valsalva aneurysm is a rare cardiac anomaly, and the difference between Asian and Western countries in its occurrence is not well established. This study was designed to investigate the difference between Asian and Western patients.

METHODS

Between September 1988 and February 2006, 83 patients with sinus of Valsalva aneurysm underwent surgical repair in our institute. The aneurysms originated from the right and noncoronary sinus in 74 and 9, respectively, and ruptured into the right ventricle in 52 patients, the right atrium in 30, and the left ventricle in 1. Ventricular septal defect (n = 38), aortic regurgitation (n = 21), and bicuspid aortic valve (n = 4) were the common coexisting anomalies. To compare the differences between Asian and Western patients in sinus of Valsalva aneurysm, 1049 cases (654 Asian patients versus 395 Western) were collected from the literature.

RESULTS

Sixty-six patients were followed up for 9.6 +/- 3.8 years. The cardiac function of 15 patients with aortic regurgitation was worse than that of those with no aortic regurgitation (p < 0.05). There was no difference between the direct closure and the patch closure (p > 0.05). Analysis of all collected cases revealed that aneurysm of the sinus of Valsalva in Asian patients compared with Western series is characterized by a higher incidence, more aneurysms originating from the right coronary sinus (85.8% versus 67.9%), more aneurysm rupture into the right ventricle (72.5% versus 60%), a higher incidence of association with ventricular septal defect (52.4% versus 37.5%), and lower incidence of association with bicuspid aortic valve (0.6% versus 7.8%). However, both Asian and Western patient series have similar incidence of combination with aortic regurgitation (33.6% versus 32.7%).

CONCLUSIONS

Long-term results of ruptured sinus of Valsalva aneurysm are associated with preoperative aortic regurgitation. The difference between Asian and Western patients with ruptured aneurysm of the sinus of Valsalva is significant.

Transcatheter closure of ruptured sinus of Valsalva aneurysm causing Fontan circulation failure

Congenital sinus of Valsalva aneurysm is a rare cardiac malformation that usually becomes symptomatic as a consequence of intracardiac or extracardiac rupture. It is difficult to suspect in association with complex cardiac defects and its rupture may be misdiagnosed as progressive aortic regurgitation. This case report refers to a patient with tricuspid atresia submitted to Fontan procedure five years previously, in whom a sinus of Valsalva aneurysm rupture into the accessory ventricular chamber caused rapidly progressive heart failure. The malformation was suspected by echocardiography and treated by percutaneous implantation of an Amplatzer duct occluder, with immediate improvement of the patient's clinical and functional status.

Sinus of Valsalva aneurysms--47 years of a single center experience and systematic overview of published reports

A retrospective study was undertaken to review demographic data, clinical presentation, outcomes, and long-term results of surgical repair of sinus of Valsalva aneurysms (SVAs). SVAs are a rare anomaly. Surgery is the treatment of choice. A retrospective review of an institutional database identified 86 patients who underwent SVA repair from 1956 to 2003. Follow-up ranged from 3 months to 40 years. The median age was 45 years (range 5 to 80). Approximately 44% of the patients had associated aortic regurgitation. Ruptures occurred in 34% of patients. The predominant fistula was from the right sinus of Valsalva to the right ventricle. Most (65%) were diagnosed by echocardiography, and the remaining (35%) were diagnosed on cardiac catheterization. All subjects underwent SVA repair. Seventy-two patients (84%) underwent other cardiac procedures at the time of aneurysm repair. Six patients (7%) died perioperatively, and the actuarial 10-year survival rate was 63%. In conclusion, echocardiography is the most frequently used diagnostic tool. The most common site of the aneurysm was the right coronary sinus. The concomitant surgical repair of associated ventricular septal defect, atrial septal defect, and the aortic valve is often required. Elective surgical repair can be performed with low risk.

Ruptured sinus of Valsalva aneurysm complicated by myocardial ischemia: pathogenetic mechanisms

Significant left-to-right shunt in combination with severe aortic regurgitation (AR) accelerates the development of symptoms after rupture of congenital sinus of Valsalva aneurysm (SVA) in spite of intact coronary arteries. We depict a rare description of a situation where acute coronary syndrome was the first manifestation of such an occurrence. We believe that the progress of the myocardial ischemia after ruptured SVA depends on the severity of AR and the quantity of the left-to-right shunt. Prompt recognition and surgical repair are indicated to prevent complications of myocardial infarction.

Modified root reconstruction methods to treat unruptured aneurysm of sinus of valsalva (UASOV)--two case reports

Abstract : Aneurysms of the Sinus of Valsalva (ASOV) are rare. We describe two cases of huge unruptured ASOV and discuss the management options. The first case was treated with sinus reconstruction and the second case was treated with "Hemiroot Replacement". One year follow up was uneventful. Although unruptured, hemodynamically significant ASOV should be treated surgically to avoid long term complications.

Aneurysms of the Sinuses of Valsalva

Sinus of Valsalva aneurysms are rare cardiac anomalies which may be acquired or congenital, most commonly involving the right or noncoronary sinuses. The congenital aneurysms are more common and often caused by weakness at the junction of the aortic media and the annulus fibrosus. Acquired aneurysms are caused by conditions affecting the aortic wall, such as infections (syphilis, bacterial endocarditis, or tuberculosis), trauma, or connective tissue disorders. Unruptured aneurysms are usually found incidentally during diagnostic studies. More commonly, sinus of Valsalvaaneurysms are diagnosed after clinical sequelae of rupture. Diagnosis of sinus of Valsalva aneurysm is facilitated by echocardiography, contrast aortography, and more recently, magnetic resonance imaging. Repair is generally required for ruptured aneurysms; unruptured aneurysms encroaching on nearby structures, causing myocardial ischemia, or having the potential to rupture warrant repair. A review of the literature is presented focusing on anatomy, clinical presentation of ruptured and unruptured aneurysms, noninvasive diagnostic modalities, and techniques for repair of this anomaly.

Aneurysm of the sinus of valsalva

Aneurysms of the sinus of Valsalva (ASVs) are rare. They can be congenital or acquired through infection, trauma, or degenerative diseases. They frequently co-occur with ventricular septal defects, aortic valve dysfunction, or other cardiac abnormalities. Although unruptured ASVs are usually asymptomatic, ruptured ASVs often cause symptoms similar to those of heart failure and produce a continuous, mechanical-sounding murmur. Transsternal or transesophageal echocardiography is usually effective in detecting ASVs. Because symptomatic ASVs pose significant risks for the patient, and because the repair of asymptomatic ASVs generally produces excellent outcomes, surgery is indicated in most cases. The primary goals of surgical repair are to close the ASV securely, remove or obliterate the aneurysmal sac, and repair any associated defects. Operative mortality is generally low except in patients with concomitant bacterial endocarditis or other infections. Late events are uncommon and tend to be related to aortic valve prothesis or Marfan syndrome.

Heart failure in rupture of a sinus of valsalva aneurysm

We report a 22-year-old man who developed shortness of breath after lifting weights and then developed acute heart failure due to rupture of an aneurysm of the right sinus of Valsalva into the right ventricle. The patient developed dyspnea, and clinical findings included tachycardia, wide pulse pressure, bounding carotid and peripheral pulses, pulmonary crackles, and prominent continuous precordial murmur with thrill. Transesophageal echocardiogram with Doppler examination confirmed the diagnosis. The patient underwent surgery with cardioplegia directly infused into the coronary arteries with excision of redundant tissue and closure of the defect with a Dacron patch. He has been asymptomatic since surgery. This condition must to be included in the differential diagnosis for young patients with heart failure.