Acquired Pseudoaneurysm of the Sinus of Valsalva

Abstract

Localized aneurysms of the sinus of Valsalva are uncommon. Repair is tailored to the defective anatomy of the sinus, the aortic valve, and the coronary artery.

Herein, we report the successful surgical treatment of 2 patients who had unruptured pseudoaneurysms of the sinus of Valsalva. An evident fissure in the intima of the sinus of Valsalva was seen in both patients. Patient 1 was a 57-year-old man with annuloaortic ectasia who was diagnosed with pseudoaneurysm of the right sinus of Valsalva. A thrombus that had formed in the pseudoaneurysm subsequently migrated into the right coronary artery. Aortic root remodeling was performed. Patient 2 was a 23-year-old man with a history of blunt chest trauma. He developed a pseudoaneurysm in the right sinus of Valsalva and tears on the aortic cusps. He underwent aortic valve replacement and repair of the Valsalva wall.

Acquired aneurysms of the sinus of Valsalva (ASVs) are reported less frequently than are congenital ASVs.^1–4 Herein, we describe the surgical treatment of 2 patients who had acquired, unruptured ASV. The causes of these aneurysms were conjectured to be an intimal fissure secondary to arteriosclerosis and annuloaortic ectasia (AAE) in Patient 1, and blunt trauma in Patient 2.

Case Reports

Patient 1

In September 2004, a 57-year-old man who had a history of hypertension and cerebellar hemorrhage was admitted to our hospital after presenting with chest pain. Transthoracic echocardiography (TTE) revealed AAE up to 67 mm, a small amount of pericardial effusion, and mild aortic regurgitation. Enhanced computed tomography and aortography did not reveal dissection of the sinus of Valsalva, and no stenotic lesion was seen on coronary angiography. Elective aortic root reconstruction was scheduled. Four weeks later, the patient again reported chest pain, and coronary angiography revealed complete occlusion of the right coronary artery. Transesophageal echocardiography (TEE) showed a tenuous line in the right sinus of Valsalva.

In the surgical reconstructive procedure, the aortic root was opened with the patient under cardioplegic arrest. The 3 sinuses of Valsalva were seen to be dilated, and a transverse fissure in the intima ran nearly the entire width of the right sinus of Valsalva between the aortic annulus and the right coronary artery orifice. A pseudoaneurysm, the cavity of which was occupied by fresh red thrombus, had formed within the intimal fissure. The right coronary artery orifice was occluded by the thrombus (Fig. 1). Saphenous vein bypass grafting to the right coronary artery was performed, as was aortic root remodeling by use of a 24-mm vascular graft. The patient's postoperative course was uneventful, and he returned to work as a crew member on an ocean liner.

Fig. 1 Patient 1. Operative photograph. The left and noncoronary sinus of Valsalva walls were resected. A thrombus was visible in the intimal fissure between the orifice of the right coronary artery (RCA) and the right coronary cusp (RCC).

NCC = noncoronary cusp

Patient 2

In November 2006, a 23-year-old, non-Marfan-type male with a history of facial and clavicular fracture from a motorcycle accident 5 years before was referred to our hospital for treatment of severe aortic regurgitation. Aortography and echocardiography revealed severe aortic regurgitation and an aneurysm on the right sinus of Valsalva (Fig. 2). At surgery, after the induction of cardioplegic arrest, a transverse fissure was detected in the intima of the right sinus of Valsalva below the right coronary artery orifice. Most of the fissure was shallow, and its maximum width was 8 mm. At the right terminus of the fissure, near the commissure of the right and noncoronary cusps, was a pseudoaneurysm of 10 mm in orifice diameter and 20 × 25 mm in total size (Fig. 3). No thrombus was visible in the cavity. Half of the left coronary cusp was detached from the annulus, and a large hole was seen in the noncoronary cusp. The right cusp, however, was intact, and there was no sign of inflammation or infection. The aortic valve was replaced with a 25-mm valve (St. Jude Medical, Inc.; St. Paul, Minn), and the right sinus of Valsalva was remodeled by use of a trimmed vascular graft. The right coronary artery was reattached to the vascular graft. The patient's postoperative course was uneventful, and he has since led a normal life.

Fig. 2 Patient 2. Aortography shows the pseudoaneurysm (arrows) beneath the right coronary artery. Severe aortic insufficiency was also observed.

Fig. 3 Patient 2. Operative photograph. An intimal fissure (*) was parallel to the annulus of the right coronary cusp. The right coronary cusp was pulled with forceps; the right end of the fissure (arrow) was conterminous with the orifice of the pseudoaneurysm.

Discussion

Congenital ASV usually protrudes and ruptures into the adjacent cardiac chamber.^1,4 Acquired ASV likely protrudes outside the cardiac chamber and occurs consequent to infection, degeneration, inflammation, or trauma.^1,4,5 Patients with ASV are typically asymptomatic unless the aneurysm ruptures or compresses cardiac components.^1,4,5

The aortic root is sometimes involved in retrograde dissection of the aorta, but dissection that is limited to the sinus of Valsalva is rare.^6,7 We found no published descriptions in English of pseudoaneurysm of the sinus of Valsalva with evident intimal fissure, such as our 2 patients presented.

Annuloaortic ectasia caused by arteriosclerosis was the presumed cause of the intimal fissure in Patient 1. We conjecture that the fissure developed in the dilated sinus of Valsalva upon the 1st occurrence of chest pain, that dissection did not extend, and that the adventitia bulged to create the pseudoaneurysm. The thrombus formed and migrated into the right coronary artery, causing the 2nd episode of pain, at which time the patient was experiencing a myocardial infarction. Compression of the coronary artery by ASV has rarely been reported to cause myocardial ischemia,1–3,7,8 and occlusion of a coronary artery by a thrombus from an ASV is exceedingly rare.^1,2 In Patient 1, the shallow ASV with thrombus was not detected on TTE or aortography, but TEE has been useful in other cases for the evaluation of a tenuous line of thrombi in ASV.^6–8

We believe that Patient 2 had a traumatic pseudoaneurysm, because it lacked an endothelium and was continuous with the intimal fissure of the sinus of Valsalva. Blunt trauma during diastolic valve-closing may cause an increase in root pressure and cause tears in components of the sinus of Valsalva.^8,9 In this patient, we speculate that small lacerations occurred at the moment of the trauma, after which the rupture of the cusps and the intimal tear gradually extended; finally, after 5 years, massive aortic regurgitation and pseudoaneurysm developed. If this sequence is accurate, it indicates that an unusually long delay can occur between trauma and the development of aortic insufficiency or a diagnosis of pseudoaneurysm.^8,10 We note further that simultaneous chronic injury to the sinus of Valsalva wall and the aortic cusps is exceedingly rare.^9,10

Localized ASV is uncommon. Various surgical treatments should be considered for different manifestations of ASV. For instance, a valve-sparing operation was performed in Patient 1, whereas in Patient 2, valve replacement and partial remodeling of the sinus of Valsalva were performed. Repair should be tailored to the defective anatomy of the sinus, the aortic valve, and the coronary artery.