Ann Thorac Surg 2002;73:1975-1977
© 2002 The Society of Thoracic Surgeons
Case report
Huge sinus of Valsalva aneurysm causing mitral valve incompetence
Wan Ki Baek, MDa,b*,
Joung Taek Kim, MDa,b,
Yong Han Yoon, MDa,b,
Kwang Ho Kim, MDa,b,
Jun Kwan, MDa,b
a Department of Thoracic and Cardiovascular Surgery, Inha University Hospital, Incheon, South Korea
b Division of Cardiology, Inha University Hospital, Incheon, South Korea
Accepted for publication December 16, 2001.
* Address reprint requests to Dr Baek, Department of Thoracic and Cardiovascular Surgery, Inha University Hospital, 7-206, 3-Ga, Shinheung-Dong, Jung-Ku, Incheon 400-103, South Korea
e-mail: wkbaek{at}inha.ac.kr
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Abstract
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We describe a case of a large sinus of Valsalva aneurysm originating from the noncoronary sinus. The aneurysm compressed the roof of the left atrium rendering the annulus and the anterior leaflet of the mitral valve severely distorted and, as a result, incompetent. The neck of the aneurysm was closed with a patch from the side of the aortic sinus, but we had to replace the mitral valve as the distorted structure did not resume its original shape even though we opened the aneurysm and debrided all thrombotic material inside the aneurysm.
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Introduction
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The usual manifestation of sinus of Valsalva aneurysm is the rupture into the right ventricle or atrium. Rarely, the aneurysm enlarges without rupture, causing symptoms of the mass effect by compressing the adjacent structures. Here, we report a case of the unusual manifestation of sinus Valsalva aneurysm in which the aneurysm compressed the left atrium, causing distortion of the mitral valve structure and, as a result, mitral valve incompetency.
A 43-year-old man presented with a month’s history of chest discomfort and cough. On physical examination, a grade III/IV systolic mitral regurgitant murmur was heard in the apex. A computed tomographic scan was obtained which demonstrated a large, round, retroaortic mass-like lesion at the level of the aortic sinus compressing the left atrium (Fig 1).
On echocardiographic examination, the lesion was revealed to have communication with the aorta and was filled with thrombotic material. Aortic regurgitation was not seen. The lesion intervened between the aortic valve and the mitral valve, and the normal relationship of the aortomitral continuity was lost. In addition, the left atrial roof was markedly compressed and prolapse of the anterior mitral valve leaflet by mass effect was observed (Fig 2).
On Doppler study, the resultant severe mitral regurgitation was seen (Fig 3).
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Fig 2. Echocardiography showing the aneurysm which intervenes between the aortic valve and the mitral valve (arrowheads). The neck of the aneurysm is marked with a white arrow. The normal relationship of the aortomitral continuity is lost and the prolapse of the anterior mitral valve leaflet is well seen. (AV = aortic valve; MV = mitral valve.)
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The operation was performed via median sternotomy and with the aid of the usual cardiopulmonary bypass. The aorta was opened and the sinus of Valsalva aneurysm was seen originating from a 15 x 10 cm discrete defect in the noncoronary sinus into the transverse sinus. The noncoronary cusp was enlarged and uniformly thickened. The left atrium was opened anterior to the right pulmonary vein, parallel to the interatrial groove. The roof of the left atrium was bulged inward, making a thorough examination of the mitral valve extremely difficult. Although we removed all of the organized thrombi in the aneurysm, via a separate incision over the aneurysmal wall between the superior vena cava and the ascending aorta, the inward bulging of the left atrial roof could not be reduced. In fact, the inward bulging and distortion of the anterior annulus and the leaflet of the mitral valve were rather organized with multiple calcific spots and thinning. Since the inward bulging of the left atrial roof definitely obscured the clear view of the whole mitral valve, which is essential for valve repair (Fig 4),
we had to replace the mitral valve. An On-X 25–27 mm mitral valve (MCRI, Austin, TX) was implanted. The defect of the aortic sinus was closed with a Dacron (C. R. Bard, Haverhill, PA) patch from the aortic side. The recovery was uneventful and the patient was sent home on the 14th postoperative day.
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Fig 4. Schematic operative drawing showing that the mitral valve is hardly visible because of the aneurysmal inward bulging of the left atrial roof.
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He is doing well at 1-year follow-up without evidence of aortic regurgitation.
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Comment
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The usual manifestation of sinus of Valsalva aneurysm is extension into cardiac chambers, most frequently into the right ventricle or the right atrium according to the location of the lesions. In most patients, the symptom is associated with the ruptured aneurysm or concomitant disease such as ventricular septal defect, aortic regurgitation, or bacterial endocarditis [1]. Rarely, the aneurysm is reported to extend outside the heart, resulting in catastrophic rupture or serious anatomic or physiologic derangement by mass and pressure effect into the adjacent structure. Compression of the left coronary artery is one of the complications so far reported [2]. We reported the unusual case of compression and derangement of the left atrial structure causing mitral regurgitation.
In current practice, mitral valve repair is recommended whenever feasible. However, in this case, we believe that mitral valve repair would not have been successful, mostly because of structual distortion of the left atrium and resultant poor visiblity of the whole mitral valve without excessive traction of the valve annulus, and partly because of organic changes of the valve annulus and leaflet.
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References
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Takach T.J., Reul G.J., Duncan M., et al. Sinus of Valsalva aneurysm or fistula: management and outcome. Ann Thorac Surg 1999;68:1573-1577.[Abstract/Free Full Text]
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Yasuda F., Shimono T., Adachi K., Onoda K., Tani K., Yada I. Surgical repair of extracardiac unruptured acquired Valsalva aneurysms. Ann Thorac Surg 2000;70:1696-1698.[Abstract/Free Full Text]
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Abstract
Introduction
