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Ann Thorac Surg 2000;70:727-729
© 2000 The Society of Thoracic Surgeons

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Original articles: cardiovascular

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

^a First Department of Surgery, Osaka University Medical School, Osaka, Japan

Address reprint requests to Dr Matuda, First Department of Surgery, Osaka University Medical School, 2–2 Yamadaoka, Suita City, Osaka 565–0871 Japan

	Abstract

Top Abstract Introduction Subjects and methods Results Comment References

 
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.

	Introduction

Top Abstract Introduction Subjects and methods Results Comment References

 
A ruptured sinus of Valsalva aneurysm is a relatively rare condition. Because of recent advances in diagnostic technique, however, the number of patients undergoing surgery have been increasing, including patients without rupture. Various surgical methods have been reported with good results, depending on the size of the aneurysm, the site of occurrence, the site of rupture, and complicating cardiac disease [1–10]. The long-term outcome after operation remains unclear, however. Notably, patients with a sinus of Valsalva aneurysm coexisting with a ventricular septal defect (VSD) plus associated aortic regurgitation (AR) have a poor prognosis. The present study was designed to assess the long-term outcome of surgical repair of a sinus of Valsalva aneurysm and the factors influencing the prognosis.

	Subjects and methods

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Between 1958 and 1996, 27 patients underwent an operation for a sinus of Valsalva aneurysm. They comprised 22 men and 5 women from 17 to 62 years old (average 34 ± 14 years). The aneurysm originated in the right coronary sinus in 17 patients, in the noncoronary sinus in 3, and in an unknown location in 7. A Valsalva aneurysm was found in only one coronary sinus in each patient. Fifteen of the 27 patients had a rupture, and the aneurysm had entered the right atrium in 3 patients, the right ventricle in 9, the left atrium in 1, and an unknown entrance site in 2. The aneurysm did not rupture in 10 patients and was unknown in 2.

Fifteen patients had acute progressive cardiac failure and 2 patients had chest pain. Six patients had no symptoms because their illness was incidentally found during a preoperative examination. The cardiac condition of the other 4 patients was unknown.

Coexistent cardiac lesions were due to congenital disease in 23 patients (with ventricular septal defect in 21, atrial septal defect in 1, and coarctation of the aorta in 1). Two patients had acquired disease (1 infection endocarditis and 1 dissection aneurysm). In addition, 16 patients had associated aortic regurgitation (AR), 13 of whom had a VSD.

We performed repairs through a right atriotomy or right ventriculotomy without aortotomy in our early works. Afterwards, we performed repairs through aortotomy avoiding right ventriculotomy. A sinus of Valsalva aneurysm was repaired by direct closure or by patch closure. For associated AR, we tried valve repair as much as possible. The closure of a VSD was performed as patch closure.

Follow-up duration was from 5 years to 34 years (14 ± 9.7).

	Results

Top Abstract Introduction Subjects and methods Results Comment References

 
All 27 patients underwent an operation and the surgical approaches are summarized in Table 1. In the early part of the series, 5 patients were repaired through a right atriotomy or right ventriculotomy. Since 1978, a combined approach through an aortotomy and pulmonary or atrial incision had been used, thereby avoiding a right ventriculotomy.

Complete heart block did not occur postoperatively, and a pacemaker was not necessary. No ventricular arrhythmias or sudden death developed in any patient in this series, including the 12 who had a right ventriculotomy.

A sinus of Valsalva aneurysm was repaired by direct closure in 22 patients and by a patch closure in 5 patients. For associated AR, a valve repair was performed in 13 patients (12 with a VSD), and a valve replacement was performed in 3.

Of the 13 patients who had an aortic valve repair, 1 died in the early recovery period and 3 died during the late recovery period of cardiac failure, infection, and as the result of a traffic accident, respectively. Reoperation for the progression of AR resulted in postoperative cardiac failure. Therefore, we began to use a combined aortotomy and pulmonary, atrial, or ventricular incision. The fistula was closed through the double approach under cardioplegia myocardial protection. However, 5 patients (all with a VSD) needed reoperation after 7 to 16 years because of reccurrent AR, and received an aortic valve replacement (Table 2). In the remaining 4 patients (all with a VSD), slightly late AR was found in 2 and they are currently being observed.

The second-operation free actuarial curve demonstrated in Figure 1 shows that patients who had an aortic valve repair had a poor prognosis. Of them, 50% needed reoperation by 10 years after the first operation.

View larger version (7K): [in this window] [in a new window]   Fig 1. Second-operation actuarial free rate in patients with sinus of Valsalva aneurysm coexisting with ventricular septal defect plus aortic regurgitation.

	Comment

Top Abstract Introduction Subjects and methods Results Comment References

The operative results for a sinus of Valsalva aneurysm was good, as has been shown in other reports. Postoperative long-term survival rate has also been good [3–10]. In our experience, the operative results and the postoperative long-term survival rate were both good. However, there were some problems among those patients who had AR coexisting with VSD [8, 9]. Aortic valve anomalies and incompetence are common in patients with a ruptured sinus of Valsalva aneurysm, particularly in cases complicated by VSD. We had no pathologic data about aortic leaflets in patients who had undergone aortic valve repair at the primary operation. Even at reoperation there were no particular findings in those patients.

Sinus of Valsalva aneurysms coexisting with VSD and originating in the right coronary sinus are common in Japan, and are often complicated by AR because of a herniation of the Valsalva aneurysm into the defective hole [1, 15]. Van Son and associates [9] reported that AR development after surgery for sinus of Valsalva aneurysms is a problem, especially in the right sinus of Valsalva to the right ventricle fistulas with associated VSD.

A delay in the timing of the operation induces a prolapsed valve, which becomes fibrotic, retracted, and deteriorated, which then precludes an adequate aortic valve repair and instead necessitates a valve replacement. Reoperation was needed in 5 patients owing to postoperative development of AR between 7 and 14 years after the first operation. All of these patients had a VSD complication. Ismail and colleagues [10] reported that an additional aortotomy as a surgical approach reduced the occurrence of late AR, but we could not find any advantage for an additional aortotomy (isolated or combined with a right ventriculotomy), and there was no correlation between a right ventriculotomy and subsequent arrhythmias or death. In a late echocardiographic study, no patient had severe ventricular dysfunction. However, we prefer to minimize the size of the right ventriculotomy or, preferably, perform the entire repair through the aorta mainly, or use a combination of approaches through the right atrium or pulmonary artery or both, whenever possible.

When treating patients with a sinus of Valsalva aneurysm coexisting with VSD and associated AR, we have found that appropriate timing of the operation is important, a forced aortic valve repair is risky, and careful observation for recurrent AR is required.

	References

Top Abstract Introduction Subjects and methods Results Comment References

 

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