Right Ventricular Outflow Tract Obstruction Caused by Isolated Sinus of Valsalva Aneurysm

Abstract

A ortic sinus of Valsalva aneurysm (SVA) is very rare, comprising <1.5% of congenital heart disease repairs.1 This type of aneurysm is usually congenital, in which instance it results from an absence of muscular and elastic tissue in the aortic wall of the sinus of Valsalva and might be associated with other heart defects.2 Recent improvements in diagnostic techniques have increased the numbers of patients who undergo surgical repair of SVA. In this report, we recount the repair of a rare unruptured large aneurysm of the right SVA that presented as right ventricular (RV) failure arising from narrowing of the RV outflow tract (RVOT). Case ReportIn April 2014, a 64-year-old man presented at our hospital with signs of RV heart failure. His history revealed multiple episodes of dyspnea during the previous month. Further investigations-starting with transthoracic echocardiography and followed by cardiac magnetic resonance imaging (CMR) and computed tomographic (CT) angiography-confirmed RVOT obstruction caused by a large aortic root aneurysm (7.6 × 5.5 cm) (Figs. 1-3).The surgical technique involved a midline sternotomy, cardiopulmonary bypass with ascending aortic and bicaval cannulation, and cardioplegic arrest. The defect was approached from the aortic root via both a transverse aortotomy and a right ventriculotomy (through the RVOT). The RV itself was seen to be substantially enlarged. The RVOT obstruction was evident: it took the form of a compression by the aortic sinus of Valsalva aneurysm (Fig. 4).We proceeded to open the ascending aorta and to expose the aortic valve. Inspection revealed a healthy tricuspid aortic valve with a large defect underneath the right coronary ostium, as had been seen upon imaging. The defect within the right sinus of Valsalva was approximately 3.0 × 5.0 cm in diameter. The view of the aneurysm through a right atriotomy and tricuspid valve was not satisfactory, however. Resection of the aneurysm was carried out through the subpulmonic RVOT incision, and this was followed by oversewing with pledgeted 4-0 Prolene sutures, in a continuous fashion. We enlarged the RVOT with bovine pericardium. After inspecting the aorta, we used a circular bovine pericardial patch and running 5-0 Prolene suture to close the SVA in a subcoronary manner. The postoperative period was uneventful, and the patient was discharged from the hospital on postoperative day 9.As part of our postoperative analysis, we performed a follow-up imaging study that included CMR 6 months after the surgical resection. There was no evidence of the right SVA, and RV systolic function had substantially improved (Fig. 5).

Case report: Total thoracoscopic repair of sinus of Valsalva aneurysm combined with ventricular septal defect

“…The endoscope provides a good view of the right coronary cusp and non-coronary cusp while exposing the infundibular VSD well (Figures 3A,B). In some cases, the SVA was associated with cardiovascular lesions, fistula opening to the right atrium, and even severe RVOT obstruction (22)(23)(24). Note such complex cardiac anomalies require more detailed surgical exploration and more manipulation instead of simple repair with patch through transaortic approach.…”