Aneurysms of the aortic sinuses of Valsalva due to bacterial endocarditis, with special reference to their operative management

Sudden Death Due to Rupture of Aneurysm of Sinus Valsalva: An Autopsy Case

ABSTRACT

Aneurysm of sinus Valsalva is a defined as dilatation of the sinuses located between the aortic valve annulus and the sinotubular junction and mostly found in the right coronary sinus. It can be either congenital or acquired. This condition is usually asymptomatic unless it can cause intracardiac rupture or aortic valve insufficiency. Extracardiac rupture and associated fatal cases of cardiac tamponade are extremely rare. Our case is one of the rare cases in the literature that was diagnosed during autopsy. Our case is 65-year-old male patient with a history of hypertension suddenly fell ill after swimming in the sea. On gross examination of heart, there was an aneurysmatic enlargement of the right sinus Valsalva measuring 4.5 × 4 cm with a hemorrhagic appearance on the outer surface and a 0.3 cm rupture area. Histopathological examination revealed hemorrhage in and around the aneurysm wall.

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.

Aneurysm of the Aortic Sinuses of Valsalva: Hemodynamics and Long-Term Prognosis After Surgery

Seventeen patients with sinus of Valsalva aneurysm are described. All of these patients have had late follow-up to assess prognosis. Twelve patients had congenital aneurysms and five were mycotic. There were 12 males and five females, ranging in age from 20 to 59 years of age (mean of 38 years). Symp toms of congestive heart failure, fatigue, and palpitations were common and were present from three days to seven years before diagnosis (mean of 13.8 months.) All patients had cardiac catheterization including aortography, and 16 had right heart catheterizations. Eleven patients (65%) had aneurysms which ruptured into another cardiac chamber, most frequently the right atrium (six patients). Eleven patients (65%) had aortic insufficiency, and it was moderate to severe in seven. New York Heart Association (NYHA) Functional Class at diag nosis was variable and did not correlate with degree of left-to-right shunt in patients with fistulas to the right heart. Functional Class seemed to correlate with the degree of aortic insufficiency.

Fourteen patients required surgery. The surgical procedure usually con sisted of repair of aneurysm and fistula when present, and aortic valve replace ment. There was one death prior to surgery and one operative death (operative mortality of 7%). Ten of the patients (66%) were in NYHA Functional Class I at late follow-up (range 2.5 to 13.1 years, mean 6.5 years). Long-term functional disability occurred more frequently in patients with moderate to severe aortic insufficiency at the time of diagnosis.

Patients with aneurysm of the sinus of Valsalva are a heterogenous popula tion. Functional Class at the time of diagnosis as well as long-term prognosis appears to be related to the presence and severity of aortic insufficiency at diagnosis. Catheterization with aortography and right heart catheterization are mandatory for accurate diagnosis. Surgical results are good with low operative mortality and improvement in long-term Functional Class.

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 aneurysm of the sinus of valsalva into the right atrium without ventricular septal defect: a case report and literature review

Aneurysm of the sinus of Valsalva (ASV), frequently associated with ventricular septal defect (VSD), is a rare cardiac disease that may be acquired or congenital. Rupture of an ASV, rare in the noncoronary cusp, usually produces serious hemodynamic change and carries poor prognosis if not treated surgically. We present the case of a 55-year-old female who came to us complaining of exertional dyspnea. Transthoracic echocardiography and aortography showed a noncoronary cusp ASV with rupture into the right atrium but without VSD. Because of high left to right shunt flow, she underwent successful surgical intervention with aneurysm repair approached from both the aorta and right atrium with a knitted Dacron patch. This was a rare case of noncoronary cusp involvement in ASV that ruptured into the right atrium without VSD.

Infective endocarditis of the aortic valve complicated by massive pericardial effusion and rupture of a sinus of valsalva into the right atrium

Infective endocarditis (IE) of the aortic valve is most commonly associated with perivalvular invasion and intracardiac fistula formation, which sometimes give rise to unpredictable clinical events. Massive pericardial effusion and aorticocardiac fistula are very rare complications of IE. We present a case in which IE of the aortic valve was initially associated with massive pericardial effusion requiring drainage and later complicated by rupture of a sinus of Valsalva with a fistula into the right atrium without formation of aneurysm. To our knowledge, the concurrent occurrence of these two events in a patient with IE has not been previously reported.

Unruptured sinus of Valsalva aneurysm in an asymptomatic patient

A 75-year-old asymptomatic male patient was referred for transesophageal echocardiography after detection of a diastolic murmur on routine physical examination and widened mediastinum on a chest radiograph. Transesophageal echocardiography revealed a large, unruptured sinus of Valsalva aneurysm, filled with a thrombus and spontaneous echocontrast and protruding into the right atrium. Unruptured sinus of Valsalva aneurysms are rare, frequently asymptomatic, and not associated with any physical findings. The diagnosis was made by transesophageal echocardiography and was confirmed by angiography and at surgery. The need for corrective surgery of asymptomatic, incidentally diagnosed sinus of Valsalva aneurysm is not well defined in the absence of precise knowledge of its natural history. We provide a description of the natural history and rationale for early corrective surgery of sinus of Valsalva aneurysms in asymptomatic patients.

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.

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.

Ruptured sinus of Valsalva aneurysm simulating endocarditis

A previously healthy, 31-year-old man was evaluated in the emergency department after being violently assaulted. A harsh, continuous murmur was noted on physical examination. Transthoracic and transesophageal echocardiograms were interpreted as showing a ruptured sinus of Valsalva aneurysm with a shunt into the right atrium and a tricuspid valve vegetation. The patient was treated with antibiotics for presumed endocarditis. Subsequent echocardiographic and surgical evaluation showed no evidence of past or present endocarditis. Rather, the sinus of Valsalva aneurysm and rupture gave the appearance of a valvular mass. This report shows some of the potential pitfalls in the delineation of abnormalities related to sinus of Valsalva aneurysms and rupture.

Mycotic aneurysms of the aortic root. A pathologic study of 20 cases

Twenty specimens of heart with mycotic aneurysms at the aortic root were studied. In ten cases, mycotic aneurysm followed infection of the aortic valve. In one case, it developed following infection of an aortic jet lesion, and in nine patients, the aneurysm was at the seat of a prosthetic aortic valve. In seven of the 11 cases with a natural aortic valve, the valve was either unicuspid or bicuspid. A retrospective evaluation of the data on the clinical records of the 20 patients revealed that infective endocarditis or noncardiac postoperative sepsis was present in 11. The most frequently isolated microorganism was Staphylococcus aureus. Conduction disturbances were found in six patients, all of them with involvement of the atrioventricular node by the aneurysm. Perforation into intracardiac cavities was found in four, two into the right ventricular infundibulum and one each into each atrium. Pericardial tamponade was caused by bleeding from the aneurysm in two cases, and myocardial infarction was a probable consequence of coronary arterial compression by the aneurysm in two cases. Mycotic aneurysms of the aortic root, in spite of their being partially or completely healed of active infection, carry a high risk of the complications enumerated. Among the 20 cases, cultures were positive in 11 and negative in nine. Staphylococcus aureus was cultured from five of the cases.

Ruptured aneurysms of the sinus of Valsalva

From 1964 to 1984, 10 male and 5 female patients with ruptured aneurysms of the sinus of Valsalva (ASVs) underwent surgical correction. These procedures constituted 0.23% of the 6,350 surgical procedures that used cardiopulmonary bypass during this period. Five patients had an inflammatory condition (bacterial endocarditis, 4; syphilis, 1), and 1 had an ASV relapse 5 years after her first operation. Coexistent lesions included aortic valve regurgitation in 5 patients, ventricular septal defect in 3 (1 of whom had mitral insufficiency), patent foramen ovale in 2, and atrial septal defect in 1. Ninety-three percent were symptomatic (sudden onset of symptoms, 5 patients; gradual onset, 9 patients), commonly with shortness of breath, fatigability, chest pain, and tachycardia. The following connections occurred: noncoronary sinus to right atrium (RA) (5 patients); right coronary sinus (RCS) to RA (5 patients); and RCS to right ventricle (5 patients). There were no early or late postoperative deaths. One patient underwent reoperation after an ASV relapse. The mean follow-up period (+/- standard deviation) was 7.9 years (range, 10 months to 20.1 years). Eighty percent of the patients were found to be in New York Heart Association class I, and 20% were in class II. Apart from ASV relapse, late complications are determined by prosthetic valve dysfunction or evidence of valve disease. Early surgical intervention is justified in patients with ruptured ASV.

Surgical management of left ventricular-aortic discontinuity complicating bacterial endocarditis

Successful hemodynamic repair of left ventricular-aortic discontinuity complicating bacterial endocarditis in 2 patients was achieved using a composite valve-woven Dacron tube graft. The prosthetic valve was sutured without tension into the remaining aortic annulus, ventricular muscle, and base of the aortic leaflet of the mitral valve. Use of the composite graft allows adequate debridement of the abscess, restores ventricular-aortic continuity, excludes the abscess wall from systemic pressure, and does not require saphenous vein coronary bypass. Total exclusion of the aortic root, as described, is a lifesaving alternative repair in the care of desperately ill patients with this condition.

Valve replacement in patients with active infective endocarditis

Eleven of 138 patients with infective endocarditis (IE) who underwent cardiac valve replacement for IE during a 12 1/2-year period had active IE. Eight of the 11 (all with aortic IE) had positive blood cultures within 48 hours preoperatively; six of the eight had positive Gram stains and cultures of the excised cardiac tissue. All 11 patients had Class IV cardiac functional disability (New York Heart Association classification) at the time of surgery. Staphylococci (three patients with Staphylococcus aureus and one with S. epidermidis) were the most frequent isolates. Three patients died; two of these three deaths occurred in patients who had a sudden onset preoperatively of severe aortic regurgitation and heart failure. In one patient (S. epidermidis infection) prosthetic valve endocarditis developed. Cardiac valve replacement may be performed successfully in patients with active IE even when blood cultures are positive in the immediate perioperative period. The hemodynamic status of patients with IE should be the determining factor in the timing of cardiac valve replacement, rather than the activity of the infection or the length of preoperative antimicrobial therapy. A radical surgical procedure may be necessary in patients with myocardial or aortic abscesses in whom conventional aortic valve replacement is not possible.

Role of cardiac catheterization in infective endocarditis

The benefits and hazards of catheterization and angiography were evaluated in 19 patients with acute aortic and/or mitral endocarditis and heart failure. In 14 patients (74%), the bedside diagnosis of valvular insufficiency and heart failure was proved correct. In three patients with both aortic and mitral valve disease, angiography (without hemodynamic measurements) was necessary to clarify the diagnosis. Angiography detected four aortic aneurysmal erosions that were unsuspected clinically, but missed three others. After angiography, heart failure worsened in two patients with severe progressive aortic insufficiency and one died. Thus, catheterization-angiography was of greatest value if more than one left-sided valve lesion was present, if extravalvular diseases mimicked heart failure, or if extravalvular infection was present. Patients with isolated, clear-cut mitral insufficiency usually do not need these diagnostic procedures, and they are probably contraindicated in patients with severe aortic regurgitation with rapidly progressing heart failure.

Congenital left aortic sinus-left ventricle fistula and review of aortocardiac fistulas

A fistula from the left aortic sinus to the left ventricle is reported that was successfully repaired using cardiopulmonary bypass. In addition, 175 cases of fistula to the heart from the aortic sinuses published in the English literature from 1839 through 1972 were studied, with particular emphasis on the 126 patients who underwent operative repair. The major cause of the fistulas (76%) was found to be rupture of a congenital aortic sinus aneurysm, usually during the third or fourth decade of life. The remainder of these fistulas to the heart consisted of simply a tract in an otherwise normal sinus. Ventricular septal defect was the most common associated defect and, when present, was nearly always related to a fistula arising from the right aortic sinus. Repair was successful in 86% of the 126 operated patients. The principles of operative treatment of these fistulas are reviewed.

Acute aortic regurgitation and abscess of sinus of Valsalva due to fulminating ulcerative endocarditis. Report of three fatal cases in children

Acute aortic regurgitation due to ulcerative endocarditis developed in 3 children aged 10, 6, and 7 years, respectively. All had congenital aortic valve lesions. Intractable congestive heart failure ensued about 2 weeks, 1 week, and a few days, respectively, after onset of infection. Two patients were operated on in the acute stage, and in both, perivalvular spread of the infection was found with abscess formation of the right sinus of Valsalva perforating through the interventricular septum to the right ventricle; valve replacement and repair were performed, but both patients died. The correct diagnosis was missed in the third patient, who was thought to have myocarditis and who died one week after onset of infection: at autopsy a perforation of a bicuspid aortic valve and an aneurysm of the sinus of Valsalva were found.

Bacterial endocarditis with ruptured sinus of Valsalva and aorticocardiac fistula

A case is presented of bacterial endocarditis with a ruptured sinus of Valsalva and formation of an aorticocardiac fistula from the right coronary sinus into the right atrium and right ventricle. The pathologic, clinical and surgical aspects of bacterial endocarditis complicated by a ruptured sinus of Valsalva and an aorticocardiac fistula are analyzed. This complication of bacterial endocarditis is still uncommon, but alertness to its diagnosis makes possible early and successful surgical treatment.

Echocardiographic manifestation of right sinus of Valsalva aneurysm

This case report describes the distinctive echocardiographic pattern in a patient with a congenital right sinus of Valsalva aneurysm. The echocardiogram demonstrated an abnormal structure extending from the aortic root into the left ventricular chamber adjacent to the interventricular septum. The structure showed diastolic motion away from the septum and systolic motion toward the septum. This movement was consistent with cineangiographic filling of the aneurysm during diastole and emptying during systole. After operative closure of the aneurysm, the echocardiogram showed dense thickening along the aortic root and contiguous interventricular septum, probably representing thrombosis and fibrosis within the obliterated aneurysmal sac; but no abnormal movement of the structure was present.