Surgical correction of recurrent rupture of congenital sinus valsalva aneurysm

Introduction: Congenital sinus of Valsalva aneurysms (SVA) are rare thin-walled saccular or tubular outpouchings ("windsock") produced by weakness of tissues at the junction of the aortic media with the annulus fibrosus. Once rupture has occurred, surgery is the treatment of choice. Various surgical closure techniques (direct suture vs patch closure) and surgical approaches (transaortic, via involved cardiac chamber or dual approaches) have been reported. This video shows the surgical correction of recurrent rupture of congenital sinus valsalva aneurysm.

Background: We report a case of a 35 year-old patient with recurrent rupture of a sinus of Valsalva aneurysm after surgical treatment at the age of 17. Primary surgery involved transatrial direct suture of a secundum ASD and transaortic direct suture of ruptured SVA using multiple interrupted sutures. Three years after surgery, echocardiographic findings showed a minimal residual aortic to RV shunt. Despite lacking clinical symptoms, series of postoperative echocardiographies showed worsening biventricular function and hamodynamic significant aortic to RV shunt. Surgery was performed to address these matters.

Surgery is performed using cardiopulmonary bypass, mild hypothermia (28°C), cardioplegic arrest and "dual exposure technique" where both the aorta and the right ventricular outflow tract (RVOT) are explored. The RVOT was opened through the free wall portion, which is shear-thinned as a consequence of chronic aortic to RV shunt. The aneurysmal sac is excised and a bovine pericardial patch is used to close the hole entering into the RV. The postoperative course was uneventful and patient was discharged home on the sixth postoperative day. Series of postoperative echocardiographies showed no residual aortic to RV shunt.

Discussion: Surgical treatment for ruptured sinus of Valsalva aneurysm is safe and has satisfactory results. It is reported that direct closure of the ruptured aneurysm has resulted in a 20% to 30% prevalence of reoperation for recurrence of the fistula or residual shunt. When the defect left by excision of the ruptured aneurysm is repaired with a patch, the need of reoperation is lower. Despite a slightly longer bypass time, we suggest adopting this technique to deal with congenital cases of ruptured or re-ruptured sinus valsalva aneurysm.