Repair of Ruptured Sinus of Valsalva Aneurysm, Ventricular Septal Defect, and Mitral Valve

A thirty-year-old male was admitted for decompensated heart failure. He had a history of a hole in the heart during childhood. The 
echocardiography on admission showed left ventricular function, an ejection fraction of 60%, a ruptured right coronary sinus of Valsalva aneurysm into the right ventricle, and severe mitral regurgitation due to the prolapse of the P2 segment of the posterior leaflet.  
He responded well to anti-failure treatment and was prepared for a patch repair of the ventricular septal defect (VSD) and right coronary sinus of Valsalva, as well as repair of the mitral valve (neochords by PTFE sutures and annuloplasty by 30mm semirigid ring). 

Intraoperative Findings 

Heart: Dilated heart, high pulmonary artery pressure, thick right atrial wall indicating long-standing right heart strain. 
 

Aorta: Ruptured aneurysm of the right coronary sinus of Valsalva aneurysm into the right ventricle, consisting of a large thin-walled sac with a perforation at the tip. After removing the sac, a small infundibular subaortic ventricular septal defect was exposed, measuring 5mm in diameter. 
 

Mitral valve: Free prolapse of myxomatous P2 segment of the posterior leaflet with elongated thin chorda and one chordlike chordae inserting into the free margin in the middle of P2. 

Technique 

The patient was put under general anesthesia in the supine position, and a median sternotomy was performed. The pericardium was opened and 3mg/kg of  
Heparin was given and repeated to maintain active coagulation time (ACT) of less than 400 seconds. Then a  
22F aortic cannula, 32 IVC cannula, and 28 SVC cannula were inserted. The coronary sinus catheter was introduced, and cardiopulmonary bypass (CPB) was started. 
 

Next, snares of cotton tapes were passed around the IVC and SVC.  
An aortic X clamp was then applied, and the heart was arrested by intermittent retrograde cold blood cardioplegia, supplemented by antegrade direct right coronary ostial infusion after opening the aorta. Following this,  
the left atrium was opened laterally through the Sondergaards groove and the aorta was opened an inch superior to sinotubular junction. Then  
the aneurysmal sac of the right coronary sinus of Valsalva was removed. The subaortic VSD was closed by a Dacron patch (Hemashield) with running 4-0 Prolene sutures. 
 

Another elliptical shape Dacron patch was used to close the defect in the right coronary sinus with running 4-0 Prolene sutures. The anterolateral margin of the defect was close to the pulmonary valve leaflets and through which pulmonary leaflets were seen. In order to avoid injuring pulmonary leaflets, the main pulmonary artery was opened and the leaflets were inspected while closure of the patch was completed. 
 

Next, the mitral valve was exposed. Multiple interrupted 2-0 Ethibond sutures were placed in the annulus in a transverse mattress fashion for the annuloplasty ring. Three 4-0 PTFE sutures were placed in the papillary muscles corresponding to left, middle, and right segments of P2 in a figure-eight fashion. The free ends of the sutures were placed in the respective free margin of P2 and locked after adjustment of the length, forming neochords. Next,  
a 30mm semirigid complete ring was fixed to the annulus by the interrupted Ethibond sutures.  
Final adjustment of the neochords was done before tying the knots. Competency of the mitral valve was confirmed by water test. 
 

The left atrial incision was closed with running 3-0 Prolene sutures in two layers, and the aortotomy incision was closed with running 4-0 Prolene sutures, also in two layers. Finally, the pulmonary aortotomy was closed with running 5-0 Prolene sutures. In the meantime, warm blood was infused through the coronary sinus catheter to aid recovery.  
 

Deairing was achieved before tying the knots and via the aortic root vent. The aortic X clamp was removed, and the heart recovered in slow junctional rhythm initially, followed by sinus rhythm a while later. 
 

After a period of reperfusion, CPB was weaned with minimum inotropic support. 
A transesophageal echocardiogram showed a competent mitral valve with no residual regurgitation, mild aortic incompetence, and no residual shunt across the patches of the sinus of Valsalva or VSD. 
 Protamine was well tolerated while the heart was decannulated. 
 

Hemostasis was achieved by replacing platelet concentrate, fibrinogen, tranexamic acid, and prothrombin complex concentrate. 
Two RV and two RA pacing wires were placed. 
Two chest tubes were placed in the pericardium, and 
the pericardium was closed. 
The wound was closed in layers.  
Finally, the patient was transferred to CTICU in stable condition. 
 

Total time on CPB was 331 minutes, and  
the aortic clamp time was 243 minutes. 

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