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Sinus Valsalva Aneurysm. Seoul National University Hospital Department of Thoracic & Cardiovascular Surgery. Sinus Valsalva Aneurysm. Definition Thin walled, saccular or tubular outpouchings, usually always in the right sinus or adjacent half of the noncoronary sinus.

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sinus valsalva aneurysm

Sinus Valsalva Aneurysm

Seoul National University Hospital

Department of Thoracic & Cardiovascular Surgery

sinus valsalva aneurysm2
Sinus Valsalva Aneurysm
  • Definition
  • Thin walled, saccular or tubular outpouchings, usually always in the right sinus or adjacent half of the noncoronary sinus.
  • They generally have an intracardiac course, but may protrude into the pericardial space and they may rupture into the right (or rarely left) heart chambers to form an aorta-cardiac fistula.
  • This defect may result from absence of normal elastic tissue and media in this region.
  • Congenitally weak area gradually enlarges under aortic pressure to form an aneurysm, although the age at which this occurs is uncertain
sinus valsalva aneurysm3
Sinus Valsalva Aneurysm
  • History
  • 1st description by Hope in 1839
  • 1st important paper published by Thurman in 1840
  • Suggested ruptured as congenital by Abbott in 1919
  • Reviewed the subject of congenital and acquired lesion

by Jones and Langley in 1949

  • 1st diagnosis of rupture during life by Venning in 1951
  • 1st. successful repair with CPB in 1956 at Mayo Clinic

& University of Minnesota using CPB

aneurysm of sinus valsalva
Aneurysm of Sinus Valsalva
  • Clinical features
  • Etiology ; congenital but other possibly acquired
  • * Endocarditis, syphilis, Behcet’s disease, atherosclerosis,
  • Cystic medial necrosis, penetrating injury
  • * Incomplete fusion of proximal & distal bulbous chordous
  • * Anatomic defect in the elastic tissue
  • * Deficiency of the conal septum
  • Rupture or fistula
  • 1) Incidence : rare ( 0.2 ~ 0.5% of open heart surgery),
  • 75% ~ 80% are male
  • 2) Site
  • * Right coronary sinus to right ventricle : 65%
  • * Noncoronary sinus to right atrium : 25%
  • * Left coronary sinus to left atrium : rarely
  • 3) Aortico-left ventricle tunnel
  • : exceedingly rare form
sinus valsalva aneurysm5
Sinus Valsalva Aneurysm
  • Etiology
  • Separation of the aortic media of the sinus from the media adjacent
  • to the hinge line of the AV valve cusp resulted from the absence
  • of normal aortic elastic tissue and media in two region.
  • Congenitally weak area gradually gives way under aortic pressure to
  • form an aneurysm.
  • The aneurysm appears an excavation of the sinus which protrudes
  • into the underlying cardiac chamber.
  • In Asians, the basic abnormality is sited leftward and toward the
  • commissural area between Rt. and Lt. cusp.
  • Acquired lesions caused by medionecrosis, syphilis, atherosclerosis,
  • endocarditis, or penetrating injury are more diffuse, involving more
  • of sinus or multiple and often ascending aorta, and projecting outside
  • the heart.
sinus valsalva aneurysm6
Sinus Valsalva Aneurysm
  • Pathophysiology
  • Thinning of the aorta medial layer in the wall of a sinus of Valsalva results in an aneurysmal dilation, which may extend and rupture into a corresponding cardiac chamber, forming an aortocardiac fistula.
  • Aneurysms usually arise from the right coronary sinus and extend into the right ventricle or right atrium.
  • Aneurysmal rupture into the right heart results in a large left-to-right shunt , which, in turn, can lead to congestive heart failure.
  • Unruptured aneurysms extending into the right heart may cause tricuspid valve stenosis/incompetence, right ventricular outflow tract obstruction, or complete heart block.
sinus valsalva aneurysm7
Sinus Valsalva Aneurysm
  • Histologic view

Unruptured aneurysm of right sinus Valsalva

Aneurysm is walled by atrophic muscular tissue of RVOT

sinus valsalva aneurysm8
Sinus Valsalva Aneurysm
  • Associated cardiac anomalies
  • VSD occurs in 30 to 50%, but may be a little higher in surgical patients.
  • Aortic valve abnormalities & incompetence are common, and when VSD is present, AR usually results from a prolapsed cusp , and when VSD is not present , AR usually arises from other valve abnormalities
  • Pulmonary stenosis is uncommon, but small gradients are common.
  • Others are uncommonly, but any defects including COA, PDA, ASD, subaortic stenosis & TOF are present.
sinus valsalva aneurysm9
Sinus Valsalva Aneurysm
  • Natural History
  • Unruptured aneurysms uncommonly cause symptoms, by
  • protrusion into RA and RV, heart block as well as ventricular
  • tachycardia may result.
  • Rupture of aneurysm tends to take place in the 3rd or 4th
  • decade of life.
  • Once symptoms develop, the heart failure worsens and, without
  • surgical treatment, most patient die within one year.
  • Clinical presentation is usually within the 3rd decade of life
  • When a VSD coexists, AV is usually at least mildly incompetent,
  • by the time 15 to 20 years, a fixed fibrous deformity of the
  • prolapsed leaflet occurs.
sinus valsalva aneurysm10
Sinus Valsalva Aneurysm
  • Clinical features
  • The SVA produce TV dysfunction or RVOT obstruction.
  • 80% of the persons with sinus Valsalva aneurysm are male.
  • Rupture produces acute symptoms in about 35% and gradual

onset of effort dyspnea in 45% and no symptoms in 20%.

  • In a few patients, death occurs within days, but in most there is

improvement, followed by recurrent symptoms.

  • The frequency of symptoms may be related to the size of the


  • Rupture is heralded not only by pain & dyspnea but also by

appearance of murmur, widened pulse pressure.

sinus valsalva aneurysm11
Sinus Valsalva Aneurysm
  • Daigram of aneurysm
  • Unruptured aneurysm of right sinus Valsalva with VSD
sinus valsalva aneurysm12
Sinus Valsalva Aneurysm
  • Daigram of aneurysm
  • Ruptured right Sinus Valsalva Aneurysm with VSD
sinus valsalva aneurysm13
Sinus Valsalva Aneurysm
  • Rupture site

Arrows indicate common sites of rupture of sinus of Valsalva aneurysm

M ; membraneous septum NC ; noncoronary sinus

V ; atrioventricular septum C ; conal septum

sinus valsalva aneurysm14
Sinus Valsalva Aneurysm
  • RVOT obstruction
sinus valsalva aneurysm15
Sinus Valsalva Aneurysm
  • Rupture
  • The sinus of origin is the main determinant of the direction of projection
  • and rupture.
  • Gradually develops a more localized windsock, in an unknown
  • percent of cases ultimately rupture into an adjacent low pressure
  • chamber and rarely outside chamber.
  • When the aneurysm coexists with a VSD(30-50%), the windsock usually projects into the RV.
  • In about one fourth, there is no windsock or any suggestion of
  • aneurysm formation, but rather, a direct fistulous communication.
  • Typical windsock deformity may be more common from right sinus
  • lesion, and a direct fistula in noncoronary sinus to RA lesion.
  • .
sinus valsalva aneurysm18
Sinus Valsalva Aneurysm
  • Sites of rupture or fistula
  • Aneurysm of the right sinus may originate more centrally and project into the outlet of RV, but leftward portion into region of
  • membranous septum.
  • Aneurysms from the noncoronary sinus usually originate from its anterior portion and rupture into the RA, but in rare cases
  • into RV, posterior portion may rupture into the pericardium.
  • Rarely, right or noncoronary sinus aneurysm rupture into LV.
  • Aneurysms from left coronary sinus rupture into the LA, LV, but rarely into LV due to thick wall and high pressure.
  • Aneurysms rupturing into areas adjacent to TV may be a cause of heart block or RBBB.
sinus valsalva aneurysm19
Sinus Valsalva Aneurysm
  • Indications for operation
  • When ruptured or is associated with VSD or with a VSD and AR, prompt operation is advisable.
  • Unruptured aneurysm that are producing
  • hemodynamic derangements should be repaired.
  • Small or moderate-sized unruptured aneurysm
  • probably should not be repaired surgically.
sinus valsalva aneurysm20
Sinus Valsalva Aneurysm
  • Techniques of operation
  • Ruptured aneurysm of right sinus Valsalva without
  • VSD
  • Ruptured aneurysm of the sinus of Valsalva into the
  • RA without VSD
  • Ruptured aneurysm of the right sinus of Valsalva
  • associated with VSD
  • * Repair by excision of aneurysm and reconstruction
  • * Repair by closing the origin of aneurysm
  • * Repair the associated VSD and valve
techniques of operation

Sinus Valsalva Aneurysm

Techniques of operation
  • Repair of ruptured aneurysm of right sinus Valsalva with VSD
techniques of operation22

Sinus Valsalva Aneurysm

Techniques of operation
  • Repair of unruptured aneurysm of right sinus Valsalva
techniques of operation23

Sinus Valsalva Aneurysm

Techniques of operation
  • Noncoronary sinus

of Valsalva aneurysm

extending into the

right atrium

techniques of operation24

Sinus Valsalva Aneurysm

Techniques of operation
  • Noncoronary sinus

of Valsalva aneurysm

extending into the

right atrium

  • VSD patch closure in

case of VSD

sinus valsalva aneurysm25
Sinus Valsalva Aneurysm
  • Techniques of operation
  • David-V valve-sparing root replacement using a De Paulis
  • Gelweave Valsalva graft
sinus valsalva aneurysm26
Sinus Valsalva Aneurysm
  • Results of operation
  • Survival
  • Risk factors for premature late death
  • 1) severe aortic incompetence
  • 2) left ventricular enlargement
  • 3) aortic valve replacement
  • Functional status
  • Persistent or worsening aortic valve incompetence
  • accounts for most of functional disability
  • Complications
  • 1) Reoperation
  • 2) Heart block
aorta right atrial tunnel
Aorta–right Atrial Tunnel
  • Clinical features
  • Aorta–right atrial tunnel (ARAT) is a very rare abnormal tubularextracardiac communication between the ascending aorta and theright atrium.
  • The first case wasdescribed in 1980 by Otero Coto and colleagues
  • Embryologic background and cause for this anomaly are not clear.
  • Probable cause seems to be a congenital deficiency of the elastic lamina inthe aortic media
  • The tunnel-like vascular extracardiac communication betweenthe aortic root and the right atrium arose from any of the 3sinuses of Valsalva.
aorta right atrial tunnel28
Aorta–right Atrial Tunnel
  • Clinical features
  • This aorto–right atrial communication behaves like a left-to-rightshunt at the atrial level.
  • The most common symptoms were shortness of breath, palpitation,and recurrent respiratory tract infections.
  • On physical examination,all patients had a continuous murmur at the right parasternalborder.
  • The single diagnostic feature is demonstration of this distincttunnel arising from one of the aortic sinuses of Valsalva andhaving an extracardiac course and entering into the right atrium
  • Treatment options are simple ligation or ligation with implantationof coronary ostium or coil embolization.