A brief patient history is given, followed by preoperative imaging, intraoperative repair, and postoperative imaging.
A 16 year old male with a history of autism spectrum disorder and COVID-19 presented with chest pain. His mother reported that she noticed a vibration on his chest. A holosystolic 3/6 murmur and 2/4 diastolic murmur were present on physical exam. Transesophageal echocardiogram demonstrated a large sinus of Valsalva aneurysm (SVA) arising from the non-coronary sinus with rupture into the right atrium. Two fenestrations were present in the aneurysm allowing for significant aorto-right atrial shunting with flow reversal in the descending aorta. Surgery for this patient was relatively elective considering his clinical stability. The patient recovered from COVID-19 prior to surgery. The aneurysm was repaired surgically with patch closure and supported by plegdeted sutures. Postoperative course included a pericardial effusion from which the patient fully recovered. He was discharged on postoperative day twelve and scheduled for appropriate follow up.
The patient was stable clinically, but his symptomatic presentation and rupture of the aneurysm made him a candidate for surgery. The patient had holosystolic and diastolic murmurs on physical exam, but he did not have other symptoms or signs of congestive heart failure, which can be seen in roughly half of patients with a ruptured SVA (1). Echocardiogram is the preferred imaging for patients with suspected SVA (2), and his preoperative echocardiogram demonstrated a ruptured windsock aneurysm communicating with the right atrium. The most common form of treatment for a ruptured SVA is surgical repair. Surgical repair diminishes the risks associated with ruptured SVAs, and there is low operative mortality (1,2). Exposure of the aneurysm from the aorta and the chamber of termination is necessary in the setting of a ruptured SVA (1). Several studies recommend closure with a patch as opposed to primary closure of the aneurysm to avoid deforming the aortic valve and to reduce stress on the suture line (1,3), though others support direct closure for small aneurysms or concomitant aortic valve replacement (AVR) (4). Additionally, the aortic root must be inspected to ensure competency and identify whether AVR is necessary. Repair of valvular abnormalities or associated defects, such as ventricular septal defects must be treated during the surgery (2).
Median sternotomy was performed and the patient was cannulated in the standard fashion. Right atriotomy was completed to expose the ruptured sinus of Valsalva aneurysm after cross clamping during cardioplegic arrest. The fenestrations of the ruptured aneurysm were occluded during cardioplegia to ensure appropriate dosing. Aortotomy was then performed, and stay sutures were placed. The origin of the sinus of Valsalva aneurysm was visualized arising from the non-coronary sinus. The left, right, and non-coronary cusps of the aortic valve were identified and examined to assess structural competence. A CardioCel bovine pericardial patch was brought to the field, sized appropriately, and sewn into the origin of the aneurysm. Once the patch was completed, the aneurysm was plicated at its neck with three felt pledgeted sutures. This was followed by primary closure of the patent foramen ovale. The aorta and right atrium were closed, and the patient was weaned off cardiopulmonary bypass.
Postoperative transesophageal echocardiogram demonstrates that the large sinus of Valsalva aneurysm arising from the non-coronary sinus and communicating with the right atrium has been closed with a patch at the sinus origin and with pledgeted imbrication sutures on the atrial side. The windsock aneurysm is no longer present, and there is no residual aorto-right atrial shunt. The patient was extubated in the operating room and was transferred to the CVICU. He sustained a pericardial effusion that was treated successfully with ibuprofen and colchicine. He was discharged on postoperative day twelve and scheduled for follow up in one week.
Surgical approaches to SVA repair include exposure of the aneurysm from the aorta, the chamber of extension, or both. If the aneurysm has ruptured, it should be exposed through the aorta and the chamber to which it extends (1), which was the technique utilized in this case. The literature indicates that the aneurysmal sac may be removed, or the surgeon may close the defect using purse-string sutures or patch repair if the defect is large (1). For our patient, the surgeon elected to close the aneurysm with a patch and buttress it with pledgeted imbrication sutures at its neck. The aneurysm was not resected due to thrombogenicity concerns.
The authors declare that they have no relationships relevant to the contents of this research to disclose.
1. Ott DA. Aneurysm of the sinus of valsalva. Semin Thorac Cardiovasc Surg Pediatr Card Surg Annu. 2006;165-176. doi:10.1053/j.pcsu.2006.02.014 2. Arcario MJ, Lou S, Taylor P, Gregory SH. Sinus of Valsalva Aneurysms: A Review with Perioperative Considerations. J Cardiothorac Vasc Anesth. 2021;35(11):3340-3349. doi:10.1053/j.jvca.2020.12.016 3. Liu YL, Liu AJ, Ling F, et al. Risk factors for preoperative and postoperative progression of aortic regurgitation in congenital ruptured sinus of Valsalva aneurysm. Ann Thorac Surg. 2011;91(2):542-548. doi:10.1016/j.athoracsur.2010.07.076 4. Wingo M, de Angelis P, Worku BM, et al. Sinus of Valsalva aneurysm repairs: Operative technique and lessons learned. J Card Surg. 2019;34(6):400-403. doi:10.1111/jocs.14041