Surgical Treatment of the Ruptured Aneurysm of the Aortic Sinuses

Transcription

1 Surgical Treatment of the Ruptured Aneurysm of the Aortic Sinuses Pan-Chih, M.D., Tsao Ching-Heng, M.D., Chen-Chun, M.D., and Liu Chieh-Fu, M.D. ABSTRACT Over the past 11 years, 51 patients (36 male, 15 female) underwent operation to correct ruptured sinus of Valsalva at the Shanghai Chest Hospital. Associated lesions were present in 36 patients. All patients had cardiac enlargement, pulmonary plethora, and prominence of the main pulmonary arterial trunk. Preoperative arterial pressure averaged 135/46 mm Hg (range, /95-0 mm Hg). At operation the cardiac chamber into which the ruptured aneurysm emptied was opened. The projecting aneurysmal sac was resected at its base, leaving a fringe of 2 to 3 mm for suturing. A double-layer suture closure was used, first a row of figure-of-eight sutures, followed by a row of buttressed mattress sutures. Forty-five patients survived operation; 6 died shortly after operation, a perioperative mortality of 11.8%. Follow-up averaged 4 years 8 months. Thirty-eight patients were symptom free and working; 7 had returned to part-time work. There were no late deaths. A grade I1 systolic murmur persists in 2 patients, and in 1 of them a loud continuous murmur and thrill were both noted. All patients who survived have shown remarkable reduction in cardiothoracic ratio and improvement in symptoms. These results justify early surgical intervention. Ruptured aneurysm of the aortic sinuses of Valsalva is a relatively rare condition. The incidence has been reported to be higher in Oriental than in Western countries. It may occur as an isolated defect or be associated with other heart anomalies. Once the aneurysm has ruptured, the pressure gradient between the aorta and the From the Department of Thoracic and Cardiovascular Surgery, Shanghai Chest Hospital, Shanghai, People's Republic of China. Presented at the Seventeenth Annual Meeting of The Society of Thoracic Surgeons, Jan 26-28,1981, Los Angeles, CA. Address reprint requests to Dr. Pan-Chih, Department of Thoracic and Cardiovascular Surgery, Shanghai Chest Hospital, 361 Peking Rd, (W) Shanghai, , People's Republic of China. affected cardiac chamber creates a large left-toright shunt. Prognosis is grave unless operative intervention is undertaken. During the past 11 years, 51 patients with ruptured sinus of Valsalva underwent corrective operation at the Shanghai Chest Hospital. The object of this paper is to consider the clinical aspects and the operative results in these patients. Material and Methods There were 36 male and 15 female patients ranging in age from 15 to 42 years (average age, 28.9 years). Associated lesions were present in 36 patients and included ventricular septa1 defect (VSD) (31), patent ductus arteriosus (1). pulmonary stenosis (l), aortic incompetence (7, 4 coincident with VSD). There were three categories of patients. Two patients (3.9%) were asymptomatic. The diagnosis was confirmed by retrograde aortography. Thirty-three patients (64.7%) had gradual onset of symptoms. Symptoms of palpitation, shortness of breath, and fatigability came on insidiously over a period of years. Sixteen patients (31.4%) experienced sudden onset of symptoms. Most of the patients in this category had a history of strenuous exertion followed by acute precordial pain and dyspnea. The preoperative arterial pressure for the series averaged mm Hg with a range of /95-0 mm Hg. All patients except 1 had the classic continuous "machinery" murmur (grade III-IV/IV) along the left sternal border, usually loudest at the third intercostal space. One patient had a systolic murmur only. Thrills were palpable in all patients. Findings on electrocardiograms included left ventricular hypertrophy in 30 patients, right ventricular hypertrophy in 2, and biventricular hypertrophy in 3. The results were normal in 4 patients. Other electrocardiographic changes by The Society of Thoracic Surgeons

2 163 Pan et al: Ruptured Aneurysm of Aortic Sinuses included atrial hypertrophy and premature beats for the remaining 12 patients. All chest roentgenograms showed obvious cardiac enlargement, pulmonary plethora, and prominence of the main pulmonary arterial trunk shadows. Preoperative retrograde aortography was carried out in 25 patients, and confirmed the ruptured aneurysm in 21. In 2 patients the cardiac catheter entered the affected cardiac chamber, thereby confirming the diagnosis. One patient was misdiagnosed as having aortopulmonary fistula and another, as having patent ductus arteriosus. Seven patients underwent right cardiac catheterization before operation. A left-to-right shunt was revealed in 6, and in the remaining patient the shunt was not evident because the aneurysm had not yet ruptured. In this patient, a pulmonary valvotomy was performed for pulmonary stenosis, and it was 8 years before the aneurysm ruptured. Operative Technique Operations were performed under cardiopulmonary bypass. The cardiac chamber into which the ruptured aneurysm emptied was Fig 1. (A) Aneurysm of aortic sinus. (B-D) Excision along dotted line, and closure of aneurysm with row of figure-of-eight sutures, followed by row of buttressed mattress sutures. (E, F) Associated ventricular defect closed by direct suture. Origin and Termination of the Ruptured Aneurysm Termination No. of Origin Patients RV RA LA R coronary sinus Noncoronary sinus L coronary sinus Unknown Total RV = right ventricle; RA = right atrium; LA = left atrium. opened. The projecting aneurysmal sac was resected at its base, leaving a fringe of 2 to 3 mm for suturing. The origins and terminations of the ruptured aneurysms were found as shown in the Table. A double-layer suture closure was used, first a row of figure-of-eight sutures and then a row of buttressed mattress sutures. The associated VSDs were usually crescent shaped and could be closed by direct suture. In only 2 patients was the VSD large enough to require patch repair (Figs 1, 2). Results Forty-five patients survived operation, and 6 died during or shortly after operation, an operative and hospital mortality of 11.8%. Three of C

3 164 The Annals of Thoracic Surgery Vol 32 No 2 August 1981 A B Fig 2. (A, B) Larger ventricular defect closed with patch. the deaths were attributable to failure to resuscitate (1) or to difficulty in resuscitation and low cardiac output (2). One death each was caused by cerebral air embolism, acute renal failure, and technical error in perfusion. Follow-up studies were carried out an average of 4 years 8 months postoperatively. Thirty-eight patients were symptom free and working full-time; 7 had returned to part-time work. There were no late deaths. A grade I1 systolic murmur persists in 2 patients; in 1 of them, both a loud continuous murmur and thrill were noted. This patient was operated on in 1966, and the murmur was noted shortly after operation. It was considered to indicate a recurrence, but she has remained well compensated and had a normal pregnancy with delivery of a full-term infant in All patients who survived operation have shown a remarkable reduction in cardiothoracic ratio as well as improvement in symptoms. These results justify early surgical intervention. Comment It is agreed, in general, that most ruptured aortic sinuses of Valsalva are congenital in origin [l, 21, but they have also been reported to occur as a result of trauma, subacute bacterial endocarditis, syphilis, and cystic medial necrosis. In 1957, Edwards and Burchell[3] stated that the basic change is lack of continuity between the aortic media and the annulus fibrosus. Taguchi and co-workers [4] suggested in 1969 that the lesion is caused by a developmental structural defect on the aortic annulus itself. The high incidence of associated VSD in our series (31 VSDs in 51 patients) also supports the argument for a congenital etiology. Preoperative retrograde aortography is essential for confirmation of the diagnosis and precise assessment of pathological anatomy. It helps not only in delineating the size and course of the ruptured aneurysms, but also in planning the operative procedure. Complete closure of the defect and simultaneous correction of associated anomalies are important. The placement of sutures requires great care as it is possible to involve or distort aortic cusps if sutures are placed too deeply. The sutures must be parallel to the long axis of the ascending aorta in order to minimize the possibility of creating aortic incompetence. Total resection of the aneurysmal sac is unnecessary; leaving a 2 to 3 mm fringe helps achieve secure suturing. Many authors have agreed that resuscitation is sometimes difficult in repair of a ruptured sinus of Valsalva [5, 61. In our early experience, we encountered 3 patients who died because of failure to resuscitate them. A protocol for resuscitation was then initiated, and since 1963, all patients have been resuscitated successfully. The measures that we are using currently include the following: 1. Strict attention to myocardial preservation. Cold cardioplegia or ice chips or both were used during aortic cross-clamping. 2. Use of a large left ventricular vent. It is important for decompressing the left ventricular cavity, lowering the left ventricular enddiastolic pressure and volume, and increasing subendocardial blood flow, particularly in the presence of aortic incompetence 17, 81.

4 165 Pan et al: Ruptured Aneurysm of Aortic Sinuses Rewarming to normothermia to minimize ventricular irritability and the likelihood of recurrent ventricular fibrillation. Synchronized assisted cardiac massage. This comprises rhythmic and even manual pressure on the lateral wall of the left ventricle (with the operator s left hand) during systole, and complete release of thh pressure during diastole. These maneuvers should be synchronized with the heartbeat. We developed this method and have been using it since It has been effective in maintaining normal heartbeat directly after resuscitation, in weaning from the pump, in increasing cardiac output, and in preventing ventricular fibrillation. Addendum In July, 1978, a group of thoracic surgeons visited the Shanghai Chest Hospital in the People s Republic of China. Among them were Dr. Gerald Rainer of Denver and his wife Lois, Dr. Harold Urschel of Dallas, and Dr. Philip Wright. Drs. Pan-Chih, Kwo, and Fu were their hosts, and they afforded the visitors the exciting opportunity to see what had been accomplished in Chinese medicine and surgery during the many years when communication between the United States and China was not possible. Dr. Pan-Chih was elected to membership in The Society of Thoracic Surgeons in January, This meeting is believed to be the first meeting of a major thoracic surgical society at which a scientific paper from the People s Republic was presented. References 1. Holmes EC, Bredenberg CE, Brawley RK: Aneurysm of the sinus of Valsalva resulting from bacterial endocarditis. Ann Thorac Surg 15:628, Hashimoto A et al: Anomaly of sinus of Valsalva and its surgical treatment. Nippon Kyobu Geka Gakkai Zasshi 26287, Edwards JE, Burchell HB: The pathological anatomy of deficiencies between the aortic root and the heart, including aortic sinus aneurysms. Thorax 12:125, Taguchi K, Sasaki N, Natsuura Y, et al: Surgical correction for aneurysm of Valsalva sinuses. Am J Cardiol23:180, Howard RJ, Moller J, Castaneda AR, et al: Surgical correction of sinus of Valsalva aneurysm. J Thorac Cardiovasc Surg 66:420, Bove KE, Schwarz DC: Aortico-left ventricular tunnel. Am J Cardiol 19:696, Archie JP, Kirklin JW: Myocardial blood flow and 8. cardiac surgery. In Kirklin JW (ed): Advances in Cardiovascular Surgery. New York, Grune & Stratton, 1973, p 189 Baird RJ, Manktelow RT, Shoh PA, et al: Intramyocardial pressure: a study of its regional variations and its relationship to intraventricular pressure. J Thorac Cardiovasc Surg 59:810, 1970 Discussion DR. GORDON K. DANIELSON (Rochester, MN): I congratulate Dr. Pan on his detailed presentations of a large number of patients with aortic sinus fistula and thank him for the opportunity of reviewing his manuscript in advance. We remain impressed by the relatively high incidence of this anomaly in Oriental compared with Western countries. For example, at our institution over the past 25 years, there have been only 25 such cases in approximately 8,000 open-heart operations for congenital heart diseases, an incidence of 0.31%. My first question for Dr. Pan is, has he noticed any familial incidence of aortic sinus fistula, which might suggest a genetic transmission such as seen in Marfan s syndrome? In other respects, the anomalies appear similar in our two countries. Although presumed to be a congenital lesion, most patients become symptomatic in adult life. The median age in our series is 30 years, comparing almost identically with the average of 29 years for Dr. Pan s patients. Similarly, one-third to one-half of patients have a sudden onset of symptoms, usually related to exertion or trauma, an unusual but well-documented feature of this anomaly. The operative mortality for repair is low; there have been no operative deaths in our series. Sections of the heart through the aortic sinuses demonstrate how a ruptured aneurysm of the sinus can form a fistula into a cardiac chamber. When the posterior sinus is in relationship to the right atrial wall, an aneurysm of the posterior aortic sinus can occur. An elastic tissue stain indicates that there is no elastin between the aortic wall and the annulus. The final result of an aneurysm of the posterior aortic sinus is rupture into the right atrium, just above the tricuspid valve. My second question is, what have you found to be the etiology of aortic sinus fistula in the People s Republic of China? Dr. Pan and his colleagues apparently did not open the aorta in any of their repairs, but they did not describe in the manuscript any aortic insufficiency murmurs postoperatively. There were two small murmurs suggesting perhaps residual VSDs and one murmur suggesting recurrent aortic sinus fistula, but none suggesting aortic insufficiency. Some surgeons have stressed that direct vision of the aortic valve is important to prevent distortion of the aortic cusps during repair of aortic sinus fistula. My last question is, on the basis of your experience, do you think that this point has been overemphasized?

5 166 The Annals of Thoracic Surgery Vol 32 No 2 August 1981 Finally, two additional approaches, which we have employed, are to repair the aortic sinus fistula and associated VSD with a single patch, and to repair both lesions through the aortic root. In this anomaly, infusion of cardioplegic solution into the aortic root is not effective, so the method of choice for administration of the cardioplegic solution is direct coronary artery perfusion. This being the case, I suspect the transaortic type of repair will become increasingly common. Thank you for the privilege of discussing this interesting paper from the People s Republic of China. DR. PAN: In answer to the first question, the high incidence of association of VSD and a lack of continuity between the aortic media and annulus itself, as sug- gested by Edwards and Burchell [3], supports those favoring a congenital etiology. In our series we have not encountered this disease among the relatives of our patients. Some of our patients had clinically insignificant diastolic murmur. I am very sorry that no detailed data can be analyzed. Second, because it is extremely difficult to obtain postmortem examination in our culture, we have had no opportunity to examine the disease histologically. Third, in our series we do not find it necessary to enter the aortic side to repair the defect. If substantial aortic insufficiency occurs, then it is logical to approach the aortic side for possible aortic valve replacement. However, the operative mortality of aortic valve replacement in this disease is very high, as reported by a Japanese series [2]. Notice from the Southern Thoracic Surgical Association The Twenty-eighth Annual Meeting of the Southern Thoracic Surgical Association will be held at The Breakers, Palm Beach, FL, Nov 5-7, There will be a $100 registration fee for nonmember physicians except for guest speakers, authors and co-authors on the program, and residents. Applications for membership should be completed by Sept 1, 1981, and forwarded to Joseph M. Craver, M.D., 1365 Clifton Road, NE, Atlanta, GA Richard B. McElvein, M.D. Secre tary-treasurer