Giant unruptured sinus of Valsalva aneurysm successfully managed with valve-sparing procedure \u2013 a case report

Miklós Pólos,Béla Merkely,Kálmán Benke,Attila Kovács,Cristina-Maria Șulea,Zoltán Szabolcs,István Hartyánszky,Hans-Joachim Schäfers,Bence Ágg

doi:10.1186/s13019-020-1061-1

Abstract

BackgroundSinus of Valsalva aneurysm (SVA) is an uncommon cardiac anomaly, with an incidence of less than 1% of open heart surgery cases. Its evolution is most frequently silent, being found incidentally or discovered in the event of its acute rupture. Non-ruptured giant SVAs may cause unusual clinical manifestations, as a consequence of their protrusion into the heart chambers or compression of the coronary vessels and are frequently associated with aortic insufficiency of various degrees of severity. The gold standard treatment for SVAs consists of complete replacement of the aortic root and valve. However, in certain cases, valve-sparing procedures may prove to be a more suitable alternative.Case presentationA 68-year-old male patient presented with dyspnea as symptom caused by a large (> 5 cm) right sinus of Valsalva aneurysm. The aneurysm was occupying most of the right ventricle and was associated with severe aortic regurgitation. The surgical treatment of the condition involved valve-sparing root reconstruction procedure (remodeling technique), completed with external stabilization of the aortic valve annulus via running suture annuloplasty. Following the uneventful intervention, the patient did well and his status improved. The follow-up transthoracic echocardiography obtained 1 month after surgery showed a fully competent aortic valve with no regurgitation.ConclusionsDespite complete aortic root and valve replacement being considered the safest approach to large SVAs complicated with aortic insufficiency, valve-sparing procedures should not be overlooked in case of a dilated aortic root with uncalcified aortic valve. Performing valve-sparing by applying a remodeling technique operation completed with annuloplasty reduces aortic valve insufficiency, avoiding side-effects related to implanted valves.

Highlights

Sinus of Valsalva Aneurysm (SVA) is considered to be an uncommon cardiac anomaly, being found in less than 1% of the cases in cardiac surgery [1]
Sinus of Valsalva aneurysm is defined as an abnormal dilatation of the aortic root situated between the aortic valve annulus and the sinotubular junction
Completed with stabilization via external suture annuloplasty described by Schäfers et al, valve-sparing procedures may offer better outcomes than the classical techniques, considering that optimal stabilization of the aortic annulus is essential for the durability of the repair [15]

Summary

Conclusions

Even in the case of large unruptured SVAs accompanied by severe aortic valve insufficiency, valve-sparing procedures may prove to be feasible. The age and functional status of the patient, as well as the possibility to avoid implanted valve side effects, may prompt repair strategy. Published data about cases of SVAs surgically managed by valve-sparing techniques is scarce. A giant SVA associated with severe aortic insufficiency surgically managed with a modified suture annuloplasty technique has not been previously reported. We present this case hoping that it will encourage surgeons to consider valve-sparing techniques as a real possibility of treatment in such cases

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