Ruptured Sinus of Valsalva Aneurysms

Abstract

Ruptured aneurysms of the aortic sinuses of Valsalva have been a surgical rarity at the Karolinska Hospital. Only nine such cases were operated on over a 13-year period (1968-1971). All nine aneurysms were of congenital type. They originated in the right coronary or the non-coronary sinus and drained into the right ventricle or the right atrium. All five ventricular entries were combined with a VSD in the membranous septum. No patient was in critical condition, despite significant left-to-right shunt and reduced aortic diastolic pressure. Aortic root angiography conclusively demonstrated the rupture per se, but even complete invasive examination failed to reveal two VSD's which were detected at surgery. Coexistent cardiac defects (5 VSD's, one ASD and one infundibular pulmonic stricture) were corrected in conjunction with the aneurysmal repair. The aneurysm was closed at its base. Isolated patched mattress sutures were always used. If tension-free approximation seemed unlikely, a patch was instead stitched to the margin of the defect. Reoperation was required in two cases because of recurrent fistulation. No patient died and the prognosis after repair appeared to be good. The transaortic supravalvular approach is preferred as the anatomically safest way to obtain closure at the aneurysmal base. A probe passed through the defect may help to identify the chamber of entry. A VSD is most likely to be present if the rupture drains into the right ventricle. These coexistent VSD's are often located in the membranous septum and they may be amenable to transaortic or transatrial repair. Opening of the right ventricle can be avoided if the right transatrial approach provides sufficient exposure to resect the aneurysmal diverticulum protruding into the right heart.