15- to 30-year follow-up of patients undergoing repair of ruptured congenital aneurysms of the sinus of Valsalva

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.

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 aneurysm repairs: Operative technique and lessons learned

OBJECTIVE

Sinus of Valsalva (SOV) aneurysms are rare and data on operative management are limited. They can cause right ventricular outflow tract or pulmonary artery compression, and rupture may be fatal. In this study, we describe our experience with the repair of 13 SOV aneurysms.

METHODS

All patients who underwent SOV aneurysm repair from May 2001 to December 2017 at our single tertiary referral center were reviewed retrospectively.

RESULTS

Thirteen patients (92% male) with a mean age of 60 years underwent repair of an SOV aneurysm; mean aneurysm diameter was 5.9 ± 0.8 cm and four patients (30.7%) presented with rupture into another cardiac chamber. Operative interventions included six Bentall procedures, five patch repairs (one with aortic valve replacement [AVR]), and two primary aneurysm closures both with concomitant AVR. There were no strokes, myocardial infarctions, re-explorations, or deaths in the postoperative period. After an average of 2.25 years, computed tomographic imaging in five patients demonstrated no aneurysm recurrence.

CONCLUSIONS

Surgery is a safe option for both ruptured and nonruptured SOV aneurysms. A variety of repair strategies may be used. Larger studies are needed.

Severe Dilatation of Coronary Artery Ostium Complicating Sinus of Valsalva Aneurysm: Differential Diagnosis and Review of the Literature

Coronary artery dilatation may be due to various aetiologies including congenital anomalies, atherosclerotic coronary disease, and Kawasakis disease. We describe a case characterised by apparent severe dilatation of the right coronary artery ostium in an asymptomatic male. Subsequent imaging and surgical intervention documented the presence of a sinus of Valsalva aneurysm extending into the ostium of the right coronary artery. This represents an unusual manifestation of a sinus of Valsalva aneurysm. The underlying pathophysiology, differential diagnosis, role of surgical management, and outcomes are discussed.

Ruptured sinus of Valsalva aneurysm from left coronary sinus into right atrium: a rare anomaly with an odd presentation

We report a case of a 42-year-old man presenting with shortness of breath and palpitation on exertion, who was evaluated to have left sinus of Valsalva aneurysm rupturing into right atrium. This is a very rare congenital cardiac anomaly with variable clinical presentation ranging from asymptomatic detection on imaging to acute coronary syndrome and sudden cardiac death. Rupture is the most dreaded complication and usually manifests as an acute event. Aneurysmal dilation less commonly affects the left sinus and rupture into the right atrium is still rarer and a chronic insidious presentation as in this case is odd.

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.

Transcatheter closure of ruptured right-coronary aortic sinus fistula to right ventricle

A 22-year-old man was referred for evaluation of exertional fatigue. On examination, there were no overt signs of congestive heart failure. Transthoracic and transesophageal echocardiography revealed rupture of the right coronary aortic sinus of Valsalva into the right ventricle. It was successfully closed with a 12 × 10 Amplatzer duct occluder.

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.

Trans-aortic repair of a sinus of valsalva aneurysm

Sinus of Valsalva aneurysms are rare and vary in their presentation and approach of surgical repair. We report on a case of isolated right sinus of Valsalva aneurysm that underwent successful excision and patch repair with individual sutures placed through the annulus of the aortic valve.

Transcatheter closure of a ruptured sinus of valsalva aneurysm

BACKGROUND

Ruptured sinus of Valsalva aneurysms (RSVA) can be associated with ventricular septal defects or isolated lesions. Surgical repair has been the traditional treatment of for the RSVA. The results of transcatheter closure of the RSVA in 4 patients are reported.

METHODS AND RESULTS

From 2003 to 2004, 4 patients (2 males and 2 females) aged from 18 years to 47 years with RSVA were identified. The diagnosis of RSVA was made based on a combination of several imaging modalities. The drainage site of the RSVA was right ventricle in 2, and right atrium in remaining 2. All patients underwent general anesthesia and transesophageal echocardiographic (TEE) monitoring during the procedure. Transcatheter closure with an Amplatzer duct occluder was attempted in all 4 patients. The size of the Amplatzer duct occluder selected was up to 2 mm larger than the maximal diameter of the aortic opening site of the RSVA as measured on TEE images. The attempt to deploy an Amplatzer duct occluder was successful in 3 and a Gianturco coil was deployed in 1. Follow-up (3-18 months) echocardiography showed neither residual shunt nor aortic regurgitation in any of the patients.

CONCLUSION

The transcatheter technique is a safe alternative in the treatment of RSVA; however, a longer follow-up is mandatory.

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.

Ruptured sinus of Valsalva aneurysm in two patients with subarterial ventricular septal defect

Rupture of a sinus of Valsalva aneurysm (SVA) is a rare, but life-threatening, event and requires immediate recognition and intervention. We present two previously healthy and physically active patients who were 12 and 33 years of age when rupture of a right coronary SVA into the right ventricle occurred. A subarterial ventricular septal defect (VSD) was detectable in both patients. Cardiac surgery involved VSD closure as well as reconstruction of the aortic valve. Considering complications of subarterial VSD, such as aortic cusp prolapse, aortic insufficiency or SVA, we suggest close follow-up and surgical closure of the VSD in case of any aortic valve deformity.

A 32-year experience with surgical repair of sinus of valsalva aneurysms

INTRODUCTION

Sinus of Valsalva (SoV) aneurysms are rare (0.15% to 1.5% CPB cases) and five times more frequent in Asians. Usually congenital, SoV aneurysms arise from the right or noncoronary sinus, are associated with other cardiac defects, and are repaired primarily or with a patch. Acquired SoV aneuryms develop secondary to infection or trauma. Here, we describe our 32-year experience with SoV aneurysm repair in a Western population.

METHODS

A retrospective review identified 22 patients who underwent SoV aneurysm repair between 1971 and 2003. Data is presented as mean +/- standard error (median).

RESULTS

Dyspnea was the most common presenting symptom. Nineteen of 22 patients were ruptured at the time of operation; three were found incidentally. Fifteen patients had associated cardiac defects including ventricular septal defect (VSD) (6), aortic insufficiency (6), and coarctation (3). One patient, repaired primarily, required reoperation for recurrence. All other patients underwent patch repair. The operative survival was 95% (21/22). There were five known late deaths at 6.6 +/- 2.3 (5.7) years post-repair. Five and ten year survival rates were 84.9 +/- 11% and 59.4 +/- 17%, respectively.

CONCLUSION

Observed differences in the sinus of origin, age at presentation, associated cardiac malformations, and mortality in our Western series versus previous Asian cohort studies likely reflect a racial disparity and higher prevalence of acquired versus congenital SoV aneurysms. We recommend a thorough search for a VSD in all cases and use of patch repair, regardless of size, to reduce risk of recurrence.

Sinus of valsalva aneurysm: surgical approaches to complicated cases

BACKGROUND

The authors herein report surgical experience with the aneurysms of sinus of Valsalva (SVA) complicated by coexisting pathologies.

METHODS

Eight patients aged between 11 and 55 years underwent surgical repair of SVA. The aneurysms originated from the right coronary sinus in four patients, from the non-coronary sinus in four patients and from the left in one patient (one patient had aneurysms originating from both the left and right sinuses). Six of the aneurysms were ruptured into the right atrium (n = 3), right ventricle (n = 2) and left ventricle (n = 2). Aortic insufficiency (AI; n = 3), ventricular septal defect (n = 2), atrial septal defect (n = 4), Marfan's syndrome (n = 2), pulmonary stenosis (n = 1) and aortic stenosis (n = 1) were the coexisting anomalies. Double-chamber exposure (right atrial/ventricle and aortic) was used in all of the patients. Patch closure was preferred for defect closure. In three patients with AI, valve replacement was necessary. Two patients with endocarditis in New York Heart Association classes III-IV underwent urgent operation.

RESULTS

The patient with annular narrowing was the only in-hospital death due to severe infection. The survivors were followed up for 85 months (range: 6-156 months). In two patients with Marfan's syndrome reoperation was necessary. All the surviving patients were asymptomatic with no unfavourable consequences.

CONCLUSIONS

Although SVA can be treated successfully with low operative risk, the factors that influence patient outcome include infective endocarditis, Marfan's syndrome and the preoperative functional status of the patient.

The Four Seasons of Ruptured Sinus of Valsalva Aneurysms: Case Presentations and Review

The sinuses of Valsalva are 3 distinct outpouchings of the aortic wall associated with the 3 cusps of the aortic valve that may develop aneurysmal dilation because of weakness of or injury to the sinus wall. Rupture of a sinus aneurysm can create an aortocardiac fistula. Ruptured sinuses of Valsalva aneurysms (RSVAs) may present a diagnostic dilemma because of their varied clinical presentations. However, if included on a differential, they are easily diagnosed and surgically treated. In our article we detail 4 RSVA cases, each demonstrating a manner in which an RSVA may present clinically. Our first case involves a 68-year-old patient with an RSVA diagnosis after presenting with cardiac arrest and congestive heart failure. Our second case involves a 42-year-old patient with an RSVA diagnosis in the context of acute chest pain, ischemic electrocardiographic changes, and hypotension. Our third RSVA case involves a 60-year-old patient who presented solely with a sudden onset of lower-extremity edema. Our fourth case involves a 46-year-old asymptomatic patient with RSVA diagnosed during a routine physical exam. Comparisons of reported case series from around the world illustrate RSVA epidemiology, concomitant lesions, clinical presentations, and repair techniques. Comparisons of Eastern and Western series reveal that the incidence of RSVAs is higher in Eastern than in Western countries, with a 4:1 male preponderance across ethnic lines. Among the Eastern series reporting RSVAs, ventricular septal defects and aortic valve incompetence were the only frequently associated concomitant lesions. In contrast, Western series of RSVAs showed a wide range of concomitant lesions. The difficulty in diagnosing RSVAs is mainly due to the variability of their clinical impact and presentation. These factors largely depend on the cardiac chamber into which the aortocardiac fistula forms. However, once RSVA is on a differential, the advent of transesophageal and transthoracic radiography has made RSVA diagnosis relatively easy. Surgical repairs of RSVAs are of low risk and generally have an excellent long-term prognosis. As a result, many authors believe that early surgical intervention in patients with an RSVA is justified. Among the series studied, there is evidence that the patch technique is the safest approach because of its lower association with fistula recurrence. This article highlights for the clinician the diversity of clinical presentations of this often overlooked disorder.

Ruptured Congenital Sinus of Valsalva Aneurysms

BACKGROUND AND AIM OF THE STUDY

Rupture of the sinus of Valsalva is rare, and there is a higher incidence of such rupture in Oriental countries than elsewhere. The objective of this study is to present the pathologic features and the clinical outcome after surgery in such patients.

METHODS

Between 1980 and 2001, a total of 17 patients (15 males and 2 females) with ruptured aneurysm of sinus of Valsalva underwent surgical intervention at the Tri-Service General Hospital, Taiwan. Their age ranged from 22 to 59 years with a mean of 33.5 years. These surgical operations made up 0.51% of the total cardiac operations (3305) performed during this period. The medical records were retrospectively reviewed.

RESULTS

The origin of the ruptured aneurysm of the sinus of Valsalva was the right coronary sinus in 12 patients, the noncoronary sinus in 4, and the left coronary sinus in one patient. The aneurysms ruptured into the right ventricle in 12 patients, into the right atrium in 3 patients, and into the left ventricle in 2 patients. Associated cardiac anomalies were aortic regurgitation in eight patients, ventricular septal defect in seven, and coronary artery fistula in one patient. There was no early postoperative death and one patient underwent a second operation after aneurysm of the sinus of Valsalva (ASV) relapse.

CONCLUSIONS

The operation for a ruptured aneurysm of sinus of Valsalva carries a low operative risk and results in excellent long-term survival after surgical treatment.

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.

Ruptured sinus of valsalva aneurysm: a Beijing experience

BACKGROUND

Ruptured sinus of Valsalva aneurysm (RSVA) is relatively common in oriental patients. We retrospectively analyzed 67 patients receiving repair of RSVA in a Beijing hospital over 5 years.

METHODS

Between October 1, 1996 and September 30, 2001, at Fu Wai Hospital, 67 patients with RSVA underwent surgical repair, 0.78% of all congenital open-heart operations. Forty-four were male and 23 female. Age ranged from 2 to 57 years old (mean 32 +/- 10 years). The RSVA originated in the right (n = 52) or noncoronary (n = 15) sinus. Rupture into the right ventricle was most common (n = 39) with 26 going to the right atrium and two to the left ventricle. Associated cardiovascular lesions were ventricular septal defect (n = 32) and aortic valve incompetence (n = 12). Repair was achieved through an incision in the cardiac chamber of the fistula exit in 61 patients. Aortotomy was used in three patients and both routes were used in three patients. The sinus of Valsalva was repaired with either a patch (n = 63) or direct sutures (n = 4). The aortic valve was replaced in 12 patients.

RESULTS

All but 1 patient (n = 66) survived the 30-day operative interval. One patient died of an anticoagulation complication 2 months after the operation. Late complications included residual shunt (n = 2), peri-prosthetic leakage (n = 1), and aortic incompetence (n = 1).

CONCLUSIONS

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

Long-term results of aortic valve regurgitation after repair of ruptured sinus of valsalva aneurysm

BACKGROUND

We reviewed our 35-year-experience to investigate the determinants of long-term results of aortic valve regurgitation (AR) after surgical repair of ruptured sinus of Valsalva aneurysms (RSVA).

METHODS

Between 1963 and 1998, a total of 35 patients aged 7 to 64 years underwent surgery for RSVA. The aneurysms ruptured into the right ventricle (n = 24), right atrium (n = 10), and left atrium (n = 1). In all, 19 patients had VSD and 9 patients had AR. A combined approach through aortotomy and the involved chamber was used for 24 patients. Either direct (n = 19) or patch (n = 16) closure was used to close the rupture hole. The AR was graded on a scale of 0 to IV by angiographic or echographic evaluation.

RESULTS

There were no early deaths. Late death occurred in 1 patient, whose AR deteriorated to grade III 20 years later. Two patients (5.7%) required reoperations on the aortic valve, because grade III AR was noted 8 and 26 years after operation, respectively. Freedom from postoperative grade III AR or higher was 93% at 10 years and was 87% at 20 years. Late AR was associated with preoperative and early postoperative AR (p < 0.05) but not with the presence of VSD, location of the fistula, surgical approach, or type of repair (direct vs patch). Multivariate analysis indicated that early postoperative AR was the only independent variable.

CONCLUSIONS

Late AR necessitating reoperation still confers significant risk in the long-term follow-up after repair of RSVA. No particular risk factor of preoperative conditions and surgical methods was elucidated in this study, and postoperative AR at discharge from the hospital was the only factor determining the long-term results of AR.

An essential role for connexin43 gap junctions in mouse coronary artery development

Connexin43 knockout mice die neonatally from conotruncal heart malformation and outflow obstruction. Previous studies have indicated the involvement of neural crest perturbations in these cardiac anomalies. We provide evidence for the involvement of another extracardiac cell population, the proepicardial cells. These cells give rise to the vascular smooth muscle cells of the coronary arteries and cardiac fibroblasts in the heart. We have observed the abnormal presence of fibroblast and vascular smooth muscle cells in the infundibular pouches of the connexin43 knockout mouse heart. In addition, the connexin43 knockout mice exhibit a variety of coronary artery patterning defects previously described for neural crest-ablated chick embryos, such as anomalous origin of the coronary arteries, absent left or right coronary artery, and accessory coronary arteries. However, we show that proepicardial cells also express connexin43 gap junctions abundantly. The proepicardial cells are functionally well coupled, and this coupling is significantly reduced with the loss of connexin43 function. Further analysis revealed an elevation in the speed of cell locomotion and cell proliferation rate in the connexin43-deficient proepicardial cells. A parallel analysis of proepicardial cells in transgenic mice with dominant negative inhibition of connexin43 targeted only to neural crest cells showed none of these coupling, proliferation or migration changes. These mice exhibit outflow obstruction, but no infundibular pouches. Together these findings indicate an important role for connexin43 in coronary artery patterning, a role that probably involves the proepicardial and cardiac neural crest cells. We discuss the potential involvement of connexin43 in human cardiovascular anomalies involving the coronary arteries.

Treatment and outcome of sinus of valsalva aneurysm

BACKGROUND

In order to understand the long-term outcome after surgical repair of sinus of Valsalva aneurysms or fistulas (SVAF), the operative results for patients treated at Shanghai Chest Hospital were retrospectively assessed.

METHODS

Between 1960 and 1999, 216 patients were operated on for SVAF. Of these 143 (66.2%) had a ventricular septal defect (VSD), 60 (28.0%) had aortic regurgitation and of these 12 underwent aortic valve replacement (AVR).

RESULTS

There were eight in-hospital deaths (3.7%). Another patient had aortic regurgitation postoperatively requiring AVR.

CONCLUSION

Resection and repair of SVAF entails an acceptably low operative risk and yields long-term freedom from symptoms. Early, aggressive operation is recommended to prevent development of complications.

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

BACKGROUND

We reviewed our experience with congenital ruptured sinus of Valsalva aneurysms (RSVA) to determine patterns of early recurrence and the fate of the aortic valve (AV).

METHODS

Over a 28-year period, RSVA was identified in 34 patients, (mean age 31.6 years). Primary closure of the RSVA was performed in 10 patients, and a patch employed in 24. Aortic insufficiency was present in 24 patients. AV replacement (AVR) was performed in 5 patients; AV repair in 6.

RESULTS

Follow-up of 9.2 +/- 8.3 years (6 months to 24 years) was complete in all but 2 patients. Five early fistula recurrences (in 4 patients) correlated with primary rather than patch closure (p < 0.03). Kaplan-Meier survival at 10 years is 90 +/- 7%. Freedom from reoperative AVR at 10 years is 83 +/- 9%. Late AVR was performed in 6 patients for progressive aortic insufficiency due to bicuspid valve (n = 3), cusp disease of affected sinus (n = 2), or aortic root dilatation (n = 2).

CONCLUSIONS

Patch closure of the RSVA should be routinely employed. A bicuspid valve may be associated with the late need for AVR.

The long-term outcome of a surgical repair of sinus of valsalva aneurysm

BACKGROUND

In order to clarify the long-term outcome after surgical repair of a sinus of Valsalva aneurysm, we retrospectively assessed the operative results for patients treated in our institute.

METHODS

The subjects were 27 patients who had undergone an operation between 1958 and 1996. For associated aortic regurgitation (AR) aortic valve repair was performed in 13 patients, 12 of whom had a ventricular septal defect (VSD); and an aortic valve replacement was performed in 3 patients, 1 of whom had a VSD.

RESULTS

Five of the 13 patients who had aortic valve repair needed aortic valve replacement because AR developed after a period of between 7 and 13 years; those cases were complicated by VSD. Another 2 patients with mild AR also complicated by VSD are currently under observation.

CONCLUSIONS

Although the postoperative outcome of the aortic valve repairs was good, cases that were complicated by VSD plus associated AR tended to develop AR later after surgery. Therefore, careful observation of the postoperative course is necessary.

Myocardial ischemia resulting from spontaneous dissection in a patient with massive bilateral sinus of valsalva aneurysms

We describe a patient with large sinus of Valsalva aneurysms involving both the left and right coronary sinuses. Spontaneous dissection of the left coronary artery occurred, causing unstable angina, a complication heretofore not associated with this disease. Successful surgical reconstruction of the aortic root, aortic valve replacement, and coronary bypass grafting were performed. Pathology revealed cystic medial necrosis.

Repair of ruptured sinus of valsalva aneurysm: determinants of long-term survival

BACKGROUND

Ruptured sinus of Valsalva aneurysm is a rare cardiac anomaly and long-term survival after surgical treatment is not well established. This study was designed to investigate the determinants of long-term survival after repair of ruptured sinus of Valsalva aneurysm.

METHODS

From April 1978 to April 1996, 53 patients underwent operation for ruptured sinus of Valsalva aneurysm. The incidence among our cardiac surgical population was 0.56%. Long-term survival was investigated in 46 patients (13 to 65 years) who survived the operation, with 96.2% follow-up completeness (mean+/-standard deviation, 6.5+/-4.9 years; maximum, 17.2 years), by univariate and multivariate analyses.

RESULTS

There was no early operative death and no recurrence after the initial repair. Actuarial survival was 83.8%+/-8.4% at 15 years. Reoperation, aneurysm draining into the left ventricle, aortic prosthetic dehiscence, bacterial endocarditis, and aortic cross-clamp time (<70 minutes) were significant factors in long-term survival (p < 0.05). Multivariate analysis revealed that only aortic prosthesis dehiscence was the significant factor influencing late survival (p = 0.0001).

CONCLUSIONS

Surgical treatment for ruptured sinus of Valsalva aneurysm is safe and has satisfactory results. Aortic prosthesis dehiscence is the independent determinant for long-term survival. Other factors including bacterial endocarditis, concomitant ventricular septal defect repair, and aortic valve replacement did not independently influence long-term survival.

Congenital sinus of Valsalva aneurysm: a multiplane transesophageal echocardiographic experience

Sinus of Valsalva aneurysm is a rare congenital anomaly which, if overlooked, may be associated with increased mortality and morbidity. Multiplane transesophageal echocardiography proved useful in identifying a variety of associated structural heart disease. This study sought to assess the accuracy of the surgical result on the basis of the multiplane transesophageal echocardiography findings and to describe patient demographics and clinical outcome in an Oriental patient cohort. From July 1984 to December 1995, clinical, catheterization, echocardiographic, and surgical results were retrospectively studied in 23 patients with documented sinus of Valsalva aneurysm. Compared with previous reports of Oriental patients, our patient cohort was older (p < 0.025), had more associated aortic, mitral, and tricuspid regurgitation (p < 0.01), but had fewer coexistent ventricular septal defects (p < 0.01), and had more associated coronary artery disease (9%). Multiplane transesophageal echocardiography precisely showed three undiagnosed and/or ambiguous transthoracic echocardiographic studies, and the preoperative transesophageal echocardiography TEE findings were confirmed intraoperatively in the last eight consecutive patients. We concluded that multiplane transesophageal echocardiography provides conclusive information and is the current technique of choice for diagnosis and clinical management of patients with sinus of Valsalva aneurysm; although the natural history of sinus of Valsalva aneurysm remains uncertain, it is likely that the incidence of unruptured sinus of Valsalva aneurysm is considerably higher in the elderly than has been previously reported.

Sinus of Valsalva aneurysms: 20 years' experience

BACKGROUND

Aneurysms of sinus of Valsalva are rare. Here, we analyze retrospectively patients operated on at our center during the last 20 years.

PATIENTS AND METHODS

One hundred four cases of congential aneurysm of sinus of Valsalva were operated upon between January 1977 and April 1996. Only 12 aneurysms were unruptured. The majority (76.9%) arose from the right coronary sinus. The right ventricle was the most common chamber of rupture (58.6%). Ventricular septal defect was associated in 46 patients (44.2%), of which 28 (60.9%) were supracristal. Ventricular septal defect was more common in aneurysms arising from the right coronary sinus (91.3%). Aortic incompetence was found in 45 patients (43.3%). The defect was closed through the aortic root alone in 24 patients (23.1%) and through both the aortic root and the chamber of rupture in the remaining 80 patients. Six patients underwent aortic valve repair, and 21 an aortic valve replacement.

RESULTS

There were two hospital deaths (1.92%). Morbidities were few. Follow-up ranged from 1 to 20 years (mean 8.2 +/- 1.1). There was one late noncardiac death, and in the majority, the long-term follow-up was uneventful.

CONCLUSION

Surgery for aneurysm of sinus of Valsalva yields gratifying results, and it should be undertaken as soon as the condition is diagnosed.

Ruptured Sinus of Valsalva Detected by Biplane Transesophageal Echocardiography

This case illustrates the importance of biplane transesophageal echocardiography and color flow Doppler imaging in detecting a sinus of Valsalva aneurysm and fistula. It also demonstrates how endocarditis can be a complication of this condition.

An uncommon cause of acute right ventricular failure and high mixed venous oxygen saturation

Ruptured sinus of Valsalva aneurysms are rare. We report a case in which the usual clinical manifestations were not present and the patient was initially treated as an acute pulmonary embolus. Despite three negative echocardiograms an intra-cardiac shunt was suspected because of a persistently elevated mixed venous oxygen saturation. Cardiac catheterisation confirmed the diagnosis. Surgical repair was performed and post operative recovery was uneventful.