Left main coronary artery compression by a left sinus of Valsalva aneurysm

Abstract

Myocardial ischaemia due to extrinsic left main coronary artery compression is unusual. Most cases are related to pulmonary hypertension with severe main pulmonary artery dilatation. An extremely rare cause is a left sinus of Valsalva aneurysm (SVA). We describe the case of a patient diagnosed of left SVA after a coronary angiography and aortography, whose initial clinical manifestation was an acute coronary syndrome complicated with an out-hospital resuscitated sudden cardiac death.Keywords: Aneurysm (aortic root) • Aortic operation • Coronary artery bypass grafts surgery CASE REPORTOn November 2011, a previously asymptomatic hypercholesterolemic 55-year old man was referred to our hospital for surgical repair after an out-of-hospital resuscitated sudden cardiac death after finishing a marathon caused by left main coronary artery (LMCA) compression by a sinus of Valsalva aneurysm (SVA). No neurological sequelae remained. He had no additional cardiovascular risk factors. On admission, physical examination and laboratory data, including cardiac enzyme levels, revealed no abnormalities. On chest X-ray, no increased cardiothoracic ratio or focal lung lesions were demonstrated and no ischaemic changes were suggested on EKG.Transthoracic and transoesophageal echocardiography demonstrated a 50-mm aortic root aneurysm with an asymmetrically enlarged left coronary sinus of Valsalva with normal heart valve function, confirmed during aortography ( Fig. 1A and B). On coronary angiography (Fig. 1C), an associated severe (70%) concentric ostial and proximal LMCA stenosis was observed, with no other significant coronary stenosis, and urgent surgical correction was indicated. Intraoperative findings included a global dilated aortic root and an asymmetric left SVA with diffuse calcified plaques and intimal ulcers extended through aortic annulus, making very difficult valve-preserving aortic root reconstruction, so we decided to perform an aortic root and valve replacement with a mechanical composite valve conduit (St Jude Medical, St Paul, MN, USA). The LMCA was compressed and enlarged by the aneurysm with a long proximal portion inlaid in its wall. The left anterior descending artery had an intramyocardial distribution on its proximal and mid portions. During coronary button tailoring, the LMCA was unavoidably transected and therefore was ligated. Coronary reconstruction included right coronary artery reimplantation and coronary artery bypass grafting (CABG) to the distal left anterior descending artery and first obtuse marginal branch with both internal thoracic arteries. On weaning of cardiopulmonary bypass ischaemic ST-segment changes were observed on precordial leads with associated echocardiographic basal anterior acinesia, and a supplemental vein graft to the first diagonal branch was performed. Afterwards, the postoperative course was uneventful. Anatomopathological analysis of the aortic root wall demonstrated atherosclerotic changes.At 3-month follow-up, the patient remained asymptomatic on New York Heart Asso...

Aneurysms of the Sinus of Valsalva Associated with Severe Aortic Valve Regurgitation

“…Unruptured SOVAs typically remain asymptomatic for decades and are often discovered incidentally on echocardiography or other imaging modalities. However, large unruptured aneurysms can produce mass effect and may cause valvular dysfunction, right ventricular outflow tract obstruction, and myocardial ischemia due to compression on the origin of the main coronary arteries [6]. Nonetheless, acute symptoms usually occur in most cases of aneurysmal rupture and subsequent fistula formation to the adjacent cardiac chamber.…”

Sinus of valsalva aneurysm repair in an octogenarian using CorMatrix ECM®

“…[9,10,18,19] Successful surgical repair was first reported in 1957 and is recommended when the sinus grows to > 50% larger than the average size of the other two sinuses, compresses surrounding chambers or origin of the main coronary arteries, increases in consecutive echocardiograms (> 0.5 cm/year) or presents incidentally during cardiac surgery. [20][21][22][23][24][25] In order to avoid complications associated with aneurysm enlargement or endocarditis, early surgical repair has been recommended especially since this surgery is associated with low morbidity and mortality, however this has not been established in elderly patients. [9,24,26] A study involving a 33-year single center experience found patients undergoing sinus of Valsalva aneurysm repairs were more commonly males (70%) and the average age was 30 years.…”

Sinus of Valsalva Aneurysm: A Rare Cause of Dyspnea

“…Unruptured SOVAs typically remain asymptomatic for decades and are often discovered incidentally on echocardiography or other imaging modalities. However, large unruptured aneurysms can produce mass effect and may cause valvular dysfunction, right ventricular outflow tract obstruction, and myocardial ischemia due to compression on the origin of the main coronary arteries [ 5 ]. Nonetheless, acute symptoms usually occur in most cases of aneurysmal rupture and subsequent fistula formation to the adjacent cardiac chamber.…”