Aneurysms of sinus of Valsalva eroding into the interventricular septum: etiopathology and surgical considerations

OBJECTIVE: To evaluate and discuss etiopathology, clinical manifestations and surgical outcome of a rare subset of unruptured aneurysm of the sinus of Valsalva which erodes into the interventricular septum. METHODS: Between 1989 and 1995, seven cases of unruptured aneurysm of the sinus of Valsalva eroding into the interventricular septum underwent surgical correction at the King Edward VII Memorial Hospital, Bombay. Theorigin of all these aneurysms was from the right coronary sinus. The mean age of presentation was 31 years. All patients were male. Calcification ofthe aneurysm was seen in three. Three patients presented without aortic regurgitation; all had complete heart block. Four patients presented with aortic regurgitation and in addition, two had complete heart block. Preoperative left ventricular function was poor in patients with aortic regurgitation (Ejection fraction range; 30-42%), when compared to those without aortic regurgitation (Ejection fraction range; 48-52%). Of those without aortic regurgitation at initial presentation, one patient developed progressive aortic regurgitation after 3 years requiring surgery. While twoother patients were operated at earliest for closure of aneurysm, even inthe absence of aortic regurgitation. All those with aortic regurgitation required surgery for aortic valve replacement and closure of aneurysm. Aneurysm was closed by direct suturing of the ostium in two patients and bypatch closure in five patients. Permanent pacemaker was implanted in five patients. RESULT: There was no operative death. Patients who underwent aortic valve replacement required post operative ionotropic support. Two patients, who underwent surgery in absence of aortic regurgitation, remain free of aortic regurgitation at the end of 36 and 42 months of follow-up. One of the patients with calcific aneurysmal sac underwent successful re-replacement of the aortic valve for paravalvar leak after a 2 year interval. CONCLUSION: Unruptured aneurysm of the sinus of Valsalva eroding into the interventricular septum should be operated at the earliest, which makes surgery simple and prevents development of complications such asaortic regurgitation and heart block.