Transaortic Approach for the Repair of RupturedAneurysms of the Sinuses of Valsalva*

HARRIS B. SHUNIACKER, JR., M.D., HAROLD KING, M.D., JOHN A. WALDHAUSEN, M.D.

Fronm the Department of Surgery and the Heart Research Center, Indiana UniversityAledical Center, Indianapolis, Indiana

IN 1961 one of us used deliberate openaortotomy and coronary perfusion in treat-ing an aneurysm of the non-coronary sinusof Valsalva with rupture into the left ven-tricle. This was believed to facilitate thesurgical correction. We have found no otherinstances in the literature in which aor-totomy and coronary perfusion were em-ploy,ed as an adjuvant in operations uponruptured aneurysms of the sinuses of Val-salva, except for the recently reported caseof Scott, Collins and Sinclair-Smith.' Wenow have employed this procedure in threeadditional cases.

In three patients, the aneur)ysm originatedin the non-coronary sinus and in one in theright coronary sinus. One communicatedwith the left ventricle, one with the rightatrium and two with the right ventricle. Inone, there was wide-open aortic valvularincompetence requiring prosthetic replace-ment in addition to closure of the fistula.This maneuver has been found to addgreatly to the safety of the operation, avoid-ance of injury to the valve leaflets andcompleteness of the repair. The purpose ofthis report is to describe our experiencewith this technic and to consider problemsrelating to accurate closure of the fistula.

* Presented before the Southern Surgical As-

sociation, Dec. 8-10, 1964, Boca Raton, Fla.Aided by grants from the United States Public

Health Service HE 02035-09 and HE 6308 andthe James Whitcomb Riley Memorial Association.

Case ReportsCase 1. A 19-year-old man had a large aneu-

rysm arising from the non-coronary sinus withrupture into the left ventricle."* Operation wasperformed on February 17, 1961. The aortic an-nulus itself separated the opening from the aorticsinus into the aneurysm and that from the aneu-rysm into the ventricle (Fig. 1). Sutures could beplaced accurately with clear visualization of theimmediately adjacent aortic leaflet. These sutureswere passed through the margins of the two de-fects and tied over strips of Teflon felt. Theclosure was complete, no aortic insufficiency re-sulted and the patient did well. He was dischargedfrom the hospital on the 10th postoperative dayand remained well. Postoperative catheterizationand cineangiographic studies carried out 5 monthsafter operation confirmed the satisfactory state ofrepair.

Case 2. A 35-year-old man was admitted tothe hospital on October 16, 1962. He had beenquite well in the past, had served in the UnitedStates Army from 1950 to 1952 and had doneordinary labor without difficulty. For 6 months,however, he noticed irregularity and "fluttering"of the heart. Three weeks before admissionhe had an illness which was thought to be "flu."He was examined on October 8 and told thathe had no heart murmur or other abnormalfindings. Two days later, while sitting quietly atwork, he noted the sudden onset of very rapidforceful beating of his heart. He was admitted toanother hospital with the presumptive diagnosis ofa ruptured aneurysm of a sinus of Valsalva andsubsequently was transferred to the UniversityMedical Center.

At the time of admission his pulse rate was 98and blood pressure 135/80. He had a typical col-

" This case has been reported previously.5

946

REPAIR OF RUPTURED ANEURYSMS

lapsing pulse, evidence of increased venous pres-

sure, and enlargement and tenderness of the liver.The precorditum was hyperactive. There was a

strong systolic thrill most palpable along the leftsternal border at the level of the fourth and fifthinterspaces. Heart tones were obscured by a con-

tinuous loud murmur. Results of electrocardiogramwere in normal limits as was the heart size on

x-ray study.Cardiac catheterization was carried out on Oc-

tober 17. A transient episode of rapid atrial fibrilla-tion followed passage of the catheter into the rightatrium. There was an average increase in oxygen

saturation in blood samples from the right ven-

tricle and pulmonary artery of between 15 and 20per cent over that of the right atrium. Calculatedpulmonary arterial blood flow at rest and withexercise (11.2 and 11.4 L./min.) was considerablymore than the systemic (6.7 and 7.8 L./min.).Wedge pulmonary capillary venous pressure was

elevated at rest (17 mm. Hg) and rose sharply inresponse to exercise (28 mm. Hg). Systolic, dias-

tolic and mean pressures in the pulmonary arterywere elevated both with rest and exercise, withvalues of 36, 21, 26 and 55, 32, 40 mm. Hg, re-

spectively. Right ventricular incompetence was in-dicated by an elevated diastolic pressure of 10 mm.Hg at rest. Following injection of contrast materialinto the supravalvular portion of the aorta, thesaccular aneurysm was demonstrated to arise in a

sinus of Valsalva and to extend inferiorly towardsthe right ventricle. There was prompt and im-mediate opacification of the right ventricle. Theaortic valve leaflets appeared competent and no

reflux into the left ventricle was observed.Despite a rigid cardiac regimen, progressive

and intractible congestive heart failure continued.Immediately before operation on October 29, theperipheral venous pressure was 21 cm. H20; tem-perature continued to rise although blood culturesremained normal.

A median sternotomy incision was made andafter cardiopulmonary bypass was established, a

decompression catheter was introduced into the

FIG. 1. Drawings of the aneurysm, fistulous openings, and method of surgical repair in Case 1.In this and the other figures the coronary perfusion catheters are omitted for sake of simplicity.

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948 SHUMACKER, KING AND WALDHAUSEN

FIG. 2. Drawings illustrate the method of re-pair from within the aorta. The fistulous openingin Case 2 was much larger than that depicted. Inthis figure and in Fig. 3 the actual aneurysm isshown as having been excised. Either a more orless horizontal or an essentially vertical aortotomyincision may be used.

left ventricle and connected with suction. Theaorta was cross-clamped and incised. A catheterwas introduced into the left coronary artery andperfusion with oxygenated blood was begun. Theheart continued to beat well. With the aorta openand the right ventricle beating strongly, the aneu-rysm herniated in a retrograde fashion back intothe aorta, arising immediately adjacent to theregion of the right coronary cusp. The sac was

excised, leaving a residual defect between theaortic annulus and the wall of the aorta approxi-mately 2 cm. centimeters long. This was closedwith interrupted Dacron sutures placed in such away as to engage the sutures in the annulus itselfand in the aortic wall along the other margin ofthe defect and not to injure the aortic leaflet (Fig.2). Even with a dry field and good visibility, con-siderable care was required in the placement ofsutures to avoid injury to the leaflet. The aortotomyincision was repaired, the coronary perfusion cathe-ter removed and the left ventricular decompression

Annals of SurgeryJune 1965

catheter withdrawn. When cardiopulmonary by-pass was discontinued, the heart action remainedgood. No thrill was palpable and the diastolicpressure was about 100.

The patient had an essentially uncomplicatedconvalescence and left the hospital on the 16thpostoperative day. He has done well, leads a nor-mal life and engages in such strenuous activitiesas basketball.

He returned to the hospital for postoperativecatheterization and cineangiographic study early inMay. The pulse rate was 80, the blood pressure120/65. The precordium was quiet and there wasno palpable thrill. There was a short Grade 2aortic systolic ejection murmur. The second soundwas normally split and was followed by a high-pitched basal diastolic murmur. The heart was notgrossly enlarged on x-ray study. Catheterization re-vealed pressure flow data to be normal at rest andin response to exercise. The blood oxygen datademonstrated no left-to-right aortic-ventricularshunt. Selective injections of contrast material intothe root of the aorta, however, demonstrated avery small residual shunt into the region of theright ventricle. It did not appear hemodynamicallyimportant.

Case 3. An 18-year-old white girl was ad-mitted to the hospital for diagnostic study on Sep-tember 15, 1963. She had been essentially asymp-tomatic although there was questionable exertionaldyspnea and palpatations. A cardiac murmur hadbeen discovered 1 month before, during the courseof a routine physical examination. Admission ex-amination revealed no evidence of failure. Thepulse was 90 and regular and the blood pressure140/64. A precordial thrill was palpable and anessentially continuous murmur with a very roughsystolic and a rather musical diastolic componentwas audible. An ejection click was thought to bepresent. Electrocardiographic tracing was consid-ered normal. Fluoroscopic and x-ray study withbarium swallow revealed the heart to be slightlyenlarged. There was evidence of possible ventricu-lar enlargement, some enlargement of the ascend-ing aorta, no definite atrial enlargement and slightincrease in pulmonary vasculature.

Cardiac catheterization revealed essentially nor-mal pressure relationships. The cardiac catheterwent from the aorta into the right atrium andright ventricle. Cineangiograms following injectionof contrast material into the supravalvular aorticarea revealed a jet passing into the right atriumwhen the tricuspid valve was closed and directlyinto the right ventricle when it was open. Dyedilution curves demonstrated the shunt at thislevel. The patient was thought to have a ruptured

REPAIR OF RUPTURED ANEURYSMS

sinus of Valsalva aneurysm entering the rightatrium between the septal and anterior tricuspidleaflets.

She was readmitted to the hospital later andoperative repair was performed on November 18.A finger was introduced into the right atrial cavityprior inserting venal caval catheters: the aneurysm

protruded into the right atrium in the region ofthe tricuspid annulus and between the septal andanterior leaflets; it also herniated between theleaflets into the ventricle whenever the tricuspidvalve was open. The usual cannulations were ac-

complished, the patient placed on cardiopulmonarybypass and a decompression catheter introducedinto the left ventricle and connected with suction.The aorta was cross-clamped and opened througha longitudinal incision which curved to the rightin the region of the non-coronary sinus. The leftcoronary orifice was identified and catheterizedand coronary perfusion was established. The heartcontinued to beat well. Inspection revealed normal-looking aortic leaflets. The origin of the aneurysm

could be seen in the non-coronary sinus very closeto the annulus. Subsequently, the atrium was

opened and the position of the aneurysm near thetricuspid annulus and in between the septal andanterior leaflets was confirmed. After the aneurysm

was excised the opening from the aorta was se-

curely closed with several Dacron sutures (Fig. 3).After closure of the defect the aortotomy andatriotomy incisions were repaired, the decompres-sion catheter removed and the operation termi-nated. Atrial fibrillation developed during thecourse of the procedure, at the conclusion of whichelectrical conversion was accomplished.

The patient had an uneventful convalescenceand was discharged from the hospital on the 7thpostoperative day. She has continued to do well.

Case 4. A 10-year-old girl was admitted tothe hospital for operative treatment on January 25,1964. A cardiac murmur had first been detected6 years previously when she was examined for an

infection of the throat. She was believed to have

rheumatic fever. When seen first in this institutionat the age of five she had evidence of wide-openaortic insufficiency. She was admitted for studyin December, 1963. Her peripheral pulses were

bounding and collapsing in character, the bloodpressure 134/54 and the cardiac rate 110/min.There was a loud aortic diastolic murmur. Theheart was considerably enlarged. There was x-ray

evidence of left ventricular and aortic enlargementand a suggestion of some left atrial enlargement.The electrocardiogram was thought to be normal.Cardiac catheterization and cineangiographic studydemonstrated marked aortic valvular insufficiencyand a small fistula from a sinus of Valsalva into

FIG. 3. Drawing illustrates, rather schematically,the anatomic situation in Case 3 and the methodof placement of sutures with visualization bothfrom within the aorta and atrium.

the right ventricle. Pressure in the right ventriclewas 27/0, in the left ventricle 114/2 and in theaorta 112/61. The patient was digitalized anddischarged to be readmitted later for operativerepair.

Operation was performed on January 27, 1964.After total cardiopulmonary bypass was instituteda left ventricular decompression catheter was in-troduced and connected with suction. The aortawas cross-clamped and opened and perfusion ofthe left coronary with oxygenated blood was begun.The heart continued to beat well. The valve leafletswere badly distorted with bulbus, thick marginsand the right coronary cusp was virtually de-stroyed. The fistula was rather small, but a

hemostat could be easily passed through it intothe right ventricle. It was situated in the regionof the non-coronary sinus immediately adjacentto the commissure between the non-coronary andright coronary cusps. The valve leaflets were ex-

cised and a ball valve prosthesis was sutured inplace in the usual manner. The fistula was repairedby direct suture and the closure was reinforcedby the Teflon ring of the ball valve prosthesiswhich was snugged up against it. The aortotomyincision was closed, the coronary perfusion catheterwithdrawn, the decompression catheter removedand the operation terminated in the usual fashion.The patient's pulse tracing, which was typical ofaortic insufficiency at the beginning, was normalat the end of the procedure.

The patient was discharged from the hospitalafter an uneventful convalescence on the 9th post-operative day. She has continued to do well. Sheis growing, gaining weight and leading a very

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active life. Her pulse rate and blood pressure arenormal. No aortic diastolic murmur is audible.Roentgenograms revcal stubstantial diminution inheart size.

Discussion

As our experience increases with intra-aortic visualization of ruptured aneurysmsof the sinuses of Valsalva in a dry field, weare continuously more impressed with itsvalue in accomplishing a secure repair with-out injury to the adjacent valve leaflet. Ineach case the institution and maintenanceof coronary perfusion has been accom-plished with ease and the heart has con-tinued to beat vigorously throughout theoperative procedure.As more cases are treated, the best

method of suture repair of the fistulouscommunication will become evident. Fromour experience it appears that the technicwill need to be varied according to theanatomic circumstances. It would seem thatthe usual case of rupture of the aneurysminto one of the ventricles, as represented byCase 2, is best managed by suture closureentirely from within the opened aorta (Fig.2). At present we are inclined to believethat this is best accomplished by passingmattress sutures through the aortic an-nulus immediately below the base of theleaflet, back into the sinus through theaortic wall on the other side of the fistulaand back again through the aortic wall andthe annulus below the origin of the leaflet.When the aortic wall in the region of thesinus appears thin, it is advisable to sup-port the suture with a small strip of Teflonfelt. All sutures should be placed ac-curately before any one is tied. The fistulararely will be associated with such severeaortic valvular disease that excision of thevalve leaflets and prosthetic valve replace-ment will be required, as in Case 4. Alsorare, as in Case 1, would be two adjacentopenings in the depths of the fairly largeand thick-walled aneurysmal sac-one intothe aortic sinus and the other into the ven-

tricle-separated by the aortic annulus it-

Annals of SurgeryJune 1965

self (Fig. 1). The repair was easily ac-complished from within the aneurysmal sac.Only, however, by being able to work in acompletely dry field, having the two open-ings clearly in view and visualizing thevalve leaflet within the aorta, was it pos-sible to place the sutures accurately so asto accomplish a secure repair and avoid in-jury to the adjacent aortic leaflet. Case 3indicated that fistulous openings betweenone of the coronary sinuses and the rightatrium can be managed advantageously byopening the atrium as well as the aorta(Fig. 3); placement of sutures, both fromwithin the aorta and within the atrium,can be watched and injury, not only to theaortic leaflet but to the tricuspid leaflets,should be avoided. If the procedure hadbeen attempted solely through the atriumin this patient, the aortic leaflet might havebeen damaged by the sutures placed in themargin of the fistula. On the other hand,had the procedure been accomplished solelythrough the opened aorta, the passage ofthe sutures probably would have injuredthe adjacent tricuspid leaflets. With boththe aorta and atrium opened, each mattresssuture can be placed from within the aorticannulus, underneath the origin of the leafletand out through the atrial side withoutpenetration of the adjacent tricuspid leaflet.The stitch can then be passed back fromthe atrium, through the aortic wall alongthe margin of the defect and out intothe coronary sinus-then directed againthrough the aortic wall back into the atriumand through the fused atrial wall and aorticannulus below the leaflet. In such cases itis also advisable to place all the sutures be-fore any one is tied.

Experience with aortic cross-clamping,aortotomy and coronary arterial perfusion,along with good vision in a dry field, showshow more blind placement of sutures couldresult in disastrous injury to the adjacentvalve leaflets. As noted by Edwards andBurchel,1 aneurysms of the aortic sinusescharateristically arise immediately adjacent

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to the annulus and the point of attachmentof the aortic leaflet. It is interesting that theoriginal repair reported by Morrow and as-sociates 3 was accomplished by drawing,more or less blindly, a molded Ivalon pros-thesis through the fistulous tract from theaorta into the right atrium in such a wayas to plug the point of origin of the fistula.This was accomplished under hypothermiaand vena caval occlusion. In another earlyoperative case, a rupture of an aneurysmof the right coronary sinus into the rightventricle, Lillihei, Stanley and Varco 2 em-ployed both aortic and ventricular incisionsand retrograde coronary sinus perfusionwith oxygenated blood. Closure was ac-complished from the aortic side. Spencer,Blake and Bahnson 6 found it necessary toopen the aorta and carry out repair fromwithin the aorta of a small child with afistula between the left coronary sinus andthe right atrium. Coronary perfusion wasnot utilized. In the one reported case 4 be-sides our own 5 in which aortotomy andcoronary arterial perfusion were deliber-ately used to facilitate repair, the fistula be-tween the right coronary sinus and the leftventricle was nicely closed.'

Summary

The use of an aortotomy incision andcoronary perfusion in cases of ruptured

* One of us (HBS) had the opportunity ofassisting Dr. Scott in this case.

aneurysms of the sinuses of Valsalva per-mits good visualization, a dry field andclosure of the defect from the point of itsorigin. As a result of experiences with thisprocedure in treating four patients, we be-lieve that it provides the most generallysatisfactory method. Each patient with-stood the procedure well, had an unevent-ful convalescence and has resumed a nor-mal life. In one patient a very tiny residualfistula which seems hemodynamically un-important remains. As experience is gainedwith this method, a complete repair with-out injury to adjacent valve leaflets shouldprove possible in every instance.

References

1. Edwards, J. E. and H. B. Burchell: The Patho-logical Anatomy of Deficiencies between theAortic Root and the Heart, Including AorticSinus Aneurysms. Thorax, 12:125, 1957.

2. Lillihei, C. W., P. Stanley and R. L. Varco:Surgical Treatment of Ruptured Aneurysmsof the Sinus of Valsalva. Ann. Surg., 146:459, 1957.

3. Morrow, A. G., R. R. Baker, H. E. Hansen andR. XV. Mattingly: Successful Repair of a Rup-tured Aneurysm of the Sinus of Valsalva.Circulation, 16:533, 1957.

4. Scott, H. W., H. A. Collins and B. Sinclair-Smith: Surgical Repair of Congenital Aneu-rysm of the Right Coronary Sinus of Valsalvawith Rupture into the Left Ventricle. J. Car-diovase. Surg., 5:231, 1964.

5. Shumacker, H. B., Jr. and W. E. Judson: Rup-ture of Aneurysm of Sinus of Valsalva intoLeft Ventricle and its Operative Repair. J.Thor. Cardiovasc. Surg., 45:650, 1963.

6. Spencer, F. C., H. A. Blake and H. T. Bahn-son: Surgical Repair of Ruptured Aneurysmof Sinus of Valsalva in Two Patients. Ann.Surg., 152:963, 1960.

DISCUSSION

DR. J. LYNWOOD HERRINGTON (Nashville):About two years ago, we had the opportunity oftreating a woman with an arterio-venous fistulainvolving the stump of the left uterine artery andhypogastric plexus of veins. This patient previ-ously had had an abdominal hysterectomy andlater a vaginal plastic. She bled following the vagi-nal plastic, which necessitated her surgeon taking

her back to the operating room and placing sev-eral sutures high on the left vaginal wall to controlthe bleeding. A few weeks later, the patient com-plained of a buzzing sensation in the left side ofher pelvis and a mass could be felt high on theleft vaginal wall. When the vagina was examined,it really gave the surgeon a thrill. I have discussedthis case with several gynecologists, each with anextensive experience with pelvic surgery, and nonehas ever encountered such a case.