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Surgery for A Sinus of Valsalva Aneurysm After Radical Repair of the Aortic Coarctation
Complex in A Young Adult with Congenital
Bicuspid Aortic Valve: A Case Report
Yoshinori Kuroda*, Tetsuro Uchida, Azumi Hamasaki, Atsushi Yamashita, Jun Hayashi and Mitsuaki Sadahiro
Department of Surgery II, Yamagata University Faculty of Medicine, Japan
Submission: September 14, 2018; Published: September 25, 2018
*Corresponding author: Yoshinori Kuroda, Department of Surgery II, Division of Cardiovascular Surgery, Yamagata University Faculty of Medicine, 2-2-2 Iidanishi, Yamagata-shi, Yamagata-ken, 990-9585, Japan, Tel: +81-23-628-5342; Email: email@example.com
How to cite this article: Yoshinori K, Tetsuro U, Azumi H, Atsushi Y, Jun H, et al. Surgery for A Sinus of Valsalva Aneurysm After Radical Repair of the Aortic
Coarctation Complex in A Young Adult with Congenital Bicuspid Aortic Valve: A Case Report. J Cardiol & Cardiovasc Ther. 2018; 12(2): 555835.
We describe a young adult who underwent surgery for sinus of Valsalva aneurysm and bicuspid aortic valve regurgitation, after undergoing radical repair of the aortic coarctation complex during childhood. A 22-year-old man had undergone radical repair for coarctation of the aorta and ventricular septal defect during childhood. He required surgical treatment of an enlarged ascending aorta and a sinus of Valsalva aneurysm with a congenital bicuspid aortic valve, as indicated using Computed Tomography (CT). Echocardiography revealed moderate regurgitation from the bicuspid aortic valve. We performed a repair of the sinus of Valsalva and replacement of the ascending aorta. Postoperatively, echocardiography revealed trivial aortic regurgitation, while CT indicated resolution of the enlarged ascending aorta and sinus of Valsalva aneurysm. The patient remains asymptomatic 1 year later. Valve sparing and aortic valve repair extensively benefit young patients exhibiting aortic root pathology following radical repair of congenital heart disease.
Keywords: Sinus of Valsalva aneurysm; Repair of the sinus of Valsalva; Aortic coarctation complex; Congenital bicuspid aortic valve
Recently, surgical outcomes for Congenital Heart Disease (CHD) have improved. As patient who underwent radical repair
for their CHD during childhood begin to age, an increasing number are now candidates for surgical treatment of another heart diseases during adulthood. Congenital Bicuspid Aortic Valve (BAV) coexisting with the Aortic Coarctation (CoA) complex is relatively common. Therefore, such patients are expected to develop aortic valve disease or aortic root disease during adulthood. We describe the surgical case of a young adult who developed sinus of a Valsalva aneurysm and BAV regurgitation after undergoing radical repair of the CoA complex during childhood.
A 22-year-old man, who underwent radical repair for CoA with Ventricular Septal Defect (VSD) during childhood, was a candidate for surgical treatment of an enlarged ascending aorta and a sinus of Valsalva aneurysm associated with BAV. Computed Tomography (CT) imaging revealed an enlarged ascending aorta
(55mm) and sinus of Valsalva aneurysm (58mm), which was
particularly prominent in the right sinus of Valsalva of the BAV (Figure 1). An innominate artery and the left common carotid artery arose from common canal, while the right subclavian artery
exhibited an aberrant origin. No stenotic lesions were identified
at the site of CoA repair. Echocardiography revealed moderate
regurgitation from the BAV, no aortic stenosis (peak pressure
gradient: 10.7mmHg) and no residual shunt following the repair
Median sternotomy was performed. Dense adhesions had
formed around the heart. Therefore, cardiopulmonary bypass was
established via the right axillary artery, right femoral artery, and
superior and inferior vena cava. The ascending aorta had enlarged
eccentrically and an aneurysm of the right sinus of Valsalva was
observed (Figure 2A). The aortic valve was bicuspid due to
fusion of the left-coronary and non-coronary cusps (Figure 2B).
Aspects of the aortic cusp were normal, and the aneurysm was
only observed at the right sinus of Valsalva. Therefore, repair of
the sinus of Valsalva was performed. The right sinus of Valsalva
was resected and reconstructed with a linguiform knitted Dacron
patch. The redundancy of cusps was assessed using Frater’s
stich and the required corrections were performed using cusp
plication. The gap of the right-coronary cusp and non-coronary
cusp at the commissure was corrected with Cabrol’s stich (Figure
2C). The ascending aorta was replaced using an artificial vascular
graft. Since the right coronary artery originating from the right
aneurysmal Valsalva wall was running intramurally, the aortic
wall around the right coronary ostium was fragile and creating
a coronary button was impossible; hence, a saphenous vein
graft was connected to the ascending aorta and right coronary
ostium (Figure 2D). Postoperatively, echocardiography revealed
trivial aortic regurgitation and no aortic stenosis (peak pressure
gradient: 5.1mmHg), and CT indicated good blood flow through
the right coronary artery as well as resolution of the enlarged
ascending aorta and sinus of Valsalva aneurysm (Figure 3). There
were no post-surgical events at one year of follow up.
Improvements in cardiovascular surgery have contributed
to enhanced CHD surgical outcomes. As results, more patients
experience a healthy adolescence after undergoing radical repair
of a CHD in childhood. Accordingly, there is an increasing number
of patients who candidates for surgical treatment for other cardiac
CoA occurs in 5-8 % of all CHD . The CoA complex is a
combination of CoA malformation and other cardiac anomalies
(commonly VSD). Additionally, congenital BAV is present in
50-70 % of CoA cases . Although the CoA complex is treated
surgically shortly after diagnosis, comorbid BAV is not usually
treated surgically unless a functional disorder arises as a result.
Persistent BAV can result in valve stenosis, regurgitation, and
eccentric enlargement of the ascending aorta [2,3].nh
The patient in the case described herein was a rare young case
of an enlarged ascending aorta and sinus of Valsalva aneurysm
that coexisted with congenital BAV following the radical repair
of the CoA complex during childhood. Some surgical cases of
sinus of Valsalva aneurysm with BAV have been reported [4,5].
Since clinicians anticipate that patients who have undergone a
radical repair of CHD will eventually require additional surgery,
cases like the one described herein will increase in frequency. The
long-term outcomes after conventional repair of CoA complex are
acceptable; however, coexisting BAV is a significant risk factor for
valve-related reinterventions .
Generally, the Bentall procedure with a composite graft,
valvular reimplantation, and aortic remodeling are the surgical
techniques of choice for resolving aortic root pathologies. The
Bentall procedure using prosthetic valve has reliably good surgical
results; however, concerns have arisen regarding complications
associated with anticoagulant therapy for mechanical valves and
the durability of bioprosthetic valves. Recently, the surgical results
of valve sparing aortic root replacement have improved , and
no anticoagulant therapy is required. As a result, this technique
confers extensive benefits on young patients. In our patient
reimplantation technique may have been suitable; however
aneurysmal change was found only at the right Valsalva sinus.
Therefore, we thought that repairing the right sinus of Valsalva
could be performed rather than a reimplantation procedure
because it would require fewer suture lines.
Aortic valve repair is a difficult technique that requires
experience and an ability to precisely evaluate the valve cusp;
however, its importance is underscored by its ability to improve
the surgical results of valve sparing procedures .
Although the surgeon and institution much determine the
most suitable procedure for each patient, the procedures of valve
sparing, and aortic valve repair confer extensive benefits for
young patients who exhibit aortic root pathology following the
radical repair of CHD.