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

1. This video illustrates surgical correction of ruptured sinus of valsalva aneurysm in 13 years old patient.

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

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

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

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

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

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

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

9. Then we proceed with opening of the aorta, the myocardial protection was completed selective ostial coronary perfusion of the cardioplegic solution

10. The communication tract of the sinus valsalva aneurysm was detected and both side opening where localized.

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

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

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

14. While the aortic site opening was closed with several interrupted suture inorder to avoid aortic valve distortion.

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

16. Patient weaned from cardiopulmonary bypass easly without inotropic support

Intra-operative post procedure echocardiogram demonstrated Intact wall between the aorta and right atrium, no residual shunt was obsereved, there was mild aortic regurgitation with no residual sub-aortic membrane.

Patient had 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.