Repair of Ruptured Sinus of Valsalva Aneurysm Via a Right Anterior Minithoracotomy

<p> The authors present the repair of a ruptured sinus of Valsalva aneurysm via a right anterior minithoracotomy. The patient presented with sinus tachycardia, a grade 4/6 pansystolic murmur, and bilateral lower extremity edema. Transesophageal echocardiogram (TEE) was performed, which revealed an 8 mm fistulous communication between the right sinus of Valsalva and the right atrium with continuous left-to-right flow directed towards the right atrium. Treatment options were discussed, and the patient opted for a minimally invasive repair.<br></p><p>The operation was performed through a 5 cm right anterior thoracotomy under videoscopic guidance. Central aortic and peripheral venous cannulation was performed under TEE guidance. Cardiopulmonary bypass (CPB) was initiated, and the patient was cooled down to 28°C. A transverse aortotomy was made in the ascending aorta, with antegrade cardioplegia being delivered directly via the right and left coronary ostia. The aorto-atrial fistula was readily identified. Patch closure of the fistula on the aortic side was performed using a Hemashield graft with running 5-0 polypropylene suture. The aortotomy was closed, the left ventricle and ascending aorta were deaired, and the aortic cross-clamp was removed. The atrial side of the defect was then addressed. The superior and inferior vena cavae were snared, and a right atriotomy was made. The windsock was easily identified and was suture ligated with 3-0 polypropylene. The right atriotomy was closed and CPB was discontinued.</p><p>Postrepair TEE revealed a well-positioned patch with no evidence of residual aorto-atrial shunt. The patient was extubated five hours postoperatively. His clinical course was unremarkable, and he was discharged home on postoperative day three. He continues to do well in outpatient follow-up.</p> <p><strong>Suggested Reading</strong></p><ol><li>Verghese M, Jairaj PS, Babuthamam C, Sukumar IP, John S. Surgical treatment of ruptured aneurysms of the sinus of Valsalva. <a href="https://www.ncbi.nlm.nih.gov/pubmed/3954500"><em>Ann Thorac Surg.</em> 1986;41(3):284-286</a>.</li><li>Vural KM, Ṣener E, Tașdemir O, Bayazit K. Approach to sinus of Valsalva aneurysms: a review of 53 cases. <a href="https://www.ncbi.nlm.nih.gov/pubmed/11423277"><em>Eur J Cardiothorac Surg.</em> 2001;20(1):71-76</a>.</li><li>Sarikaya S, Adademir T, Elibol A, Büyükbayrak F, Onk A, Kirali K. Surgery for ruptured sinus of Valsalva aneurysm: 25-year experience with 55 patients. <a href="https://doi.org/10.1093/ejcts/ezs450"><em>Eur J Cardiothorac Surg.</em> 2013;43(3):591-596</a>.</li><li>Xiao JW, Wang QG, Zhang DZ, et al. Clinical outcomes of percutaneous or surgical closure of ruptured sinus of Valsalva aneurysm. <a href="https://doi.org/10.1111/chd.12572"><em>Congenit Heart Dis.</em> 2018;13(2):305-310</a>.</li></ol>