A 78-yr-old male experienced an episode of shortness of breath and hypotension during hemorrhoid surgery performed under local anesthesia. His medical history was significant for hypercholesterolemia, benign prostate hypertrophy, and a history of gastroesophageal reflux. Subsequent workup revealed a new high-pitched systolic murmur, severe mitral regurgitation (MR), and a Sinus of Valsalva (SVA) aneurysm of the aorta. He was referred for mitral valve surgery and SVA repair. On the morning of surgery, coronary artery catheterization revealed a significant lesion in the left anterior descending coronary artery.
Intraoperative multiplane transesophageal echocardiography (TEE) confirmed the preoperative diagnosis of severe MR. A midesophageal four-chamber TEE view revealed an SVA extending towards the right ventricle (RV) (Fig. 1, above). A midesophageal aortic valve (AV) long axis view of the AV confirmed the presence of an SVA primarily involving the right cusp of the AV (Fig. 1, below; please see video loop available at www.anesthesia-analgesia.org) and trace/mild aortic insufficiency (AI) by color flow Doppler. The TEE probe was advanced to the transgastric depth and the multiplane angle rotated to 20° to obtain a modified transgastric RV inflow view that demonstrated the SVA bulging into the RV outflow tract (RVOT) (Fig. 2, above). Color flow Doppler showed turbulent flow at the level of the SVA bulging into the RVOT. In addition a continuous wave Doppler beam oriented parallel to flow through the RVOT demonstrated a mild obstruction consistent with a peak velocity of 1.8 m/s, corresponding to a calculated peak pressure gradient of 13 mm Hg (Fig. 2).
Surgical exposure of the mitral valve revealed a flail middle scallop (P2), which was repaired and reinforced with a 28-mm Cosgrove ring. The left internal mammary artery was grafted to the left anterior descending coronary artery. The SVA was repaired with a Gore-Tex® Patch measuring 1.5 × 0.5 cm, and the patient was weaned uneventfully from cardiopulmonary bypass. Post-cardiopulmonary bypass TEE showed trace MR, confirmed the repaired SVA, persistent trace AI, and an RVOT that was free of anatomic and functional obstruction. The patient had an uneventful postoperative course.
SVA is relatively uncommon with an incidence of 0.14%-0.23% (1). Frequently a bicuspid AV and AI are associated with SVA (2). Complications of this entity often diagnosed by echocardiography include rupture of the aneurysm into one of the cardiac chambers, cardiac tamponade, endocarditis, and myocardial infarction. In the presented case, intraoperative TEE confirmed the preoperative diagnosis of a SVA, and revealed previously unknown RVOT obstruction, a rare phenomenon associated with congenital SVA (3). After surgical correction, the absence of anatomic or functional abnormalities of the AV and the RVOT were confirmed by intraoperative TEE.
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3. Ring WS. Congenital heart surgery nomenclature and database project: aortic aneurysm, sinus of Valsalva aneurysm, and aortic dissection. Ann Thorac Surg 2000;69:S147–63.