Surgical Correction of Ruptured Sinus of Valsalva Aneurysm in a Patient With Bicuspid Aortic Valve

This video illustrates the surgical correction of ruptured sinus of Valsalva aneurysm in a 13-year-old patient.

1. The patient had an initial diagnosis of moderate aortic valve regurgitation on functional bicuspid aortic valve.

2. Preoperative echogram studies showed a mobile, round, cystic mass close to the right atrial septum just above the septal leaflet of the tricuspid which was associated with moderate shunt flow from the aorta to the right atrium.

3. The patient already had moderate aortic valve regurgitation in addition to sub-aortic membrane.

4. The heart was approached through median sternotomy and CPB was started through aorto-bicaval cannulations.

5. Initially the cardioplegic solution was administered through the aortic root and then directly to the coronary ostium selectively after aorotomy.

6. After aortic cross clamp, the right atrium was opened: the cystic mobile lesion was identified and examined carefully.

7. The atrial site opening of the aneurysmatic lesion was noted, where the cardioplegic solution was leaking through.

8. Then we proceeded with the opening of the aorta and myocardial protection was completed.

9. The communication tract of the sinus of Valsalva aneurysm was detected and both side openings where localized.

10. The aneurysmatic membrane in the right atrial side was completed resected.

11. Then, through the aortic valve, the subaortic membrane was removed and septal myectomy was performed.

12. Then, through multiple interrupted sutures. the right atrial opening of the defect was closed using bovine pericardial patch.

13. The aortic site opening was closed with several interrupted sutures in order to avoid aortic valve distortion.

14. Then the aortotomy was closed in direct sutures and the same for right atrial incision.

15. The patient was weaned from cardiopulmonary bypass easily without inotropic support.

Intraoperative post-procedure echocardiogram demonstrated an intact wall between the aorta and right atrium; no residual shunt was observed. There was mild aortic regurgitation with no residual sub-aortic membrane. The patient had an uneventuful post-operative course and was discharged home in excellent clinical condition.

References

1. Aggarwal SK, Iyer VR. Ruptured sinus of Valsalva with bicuspid aortic valve. Clin Cardiol. 2009 Jun;32(6):E97-8. doi: 10.1002/clc.20103. PMID: 17614293; PMCID: PMC6653031.
2. Xu M, Song L, Tao L, Xiao H. Surgical repair of a quadricuspid aortic valve associated with a ruptured sinus of Valsalva aneurysm. J Thorac Cardiovasc Surg. 2020 Jun;159(6):e341-e342. doi: 10.1016/j.jtcvs.2019.06.085. Epub 2019 Jul 18. PMID: 31409494.
3. Budts W, Moons P, Mertens L, Van de Werf F. Ruptured aneurysm of the sinus of Valsalva into the right atrium. An uncommon congenital heart defect. Acta Clin Belg. 2003 Mar-Apr;58(2):120-2. PMID: 12836495.
4. Wingo M, de Angelis P, Worku BM, Leonard JR, Khan FM, Hameed I, Lau C, Gaudino M, Girardi LN. Sinus of Valsalva aneurysm repairs: Operative technique and lessons learned. J Card Surg. 2019 Jun;34(6):400-403. doi: 10.1111/jocs.14041. Epub 2019 Apr 6. PMID: 30953447.

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