Long-term outcome of surgical repair of ruptured sinus of Valsalva aneurysm.

BACKGROUND

Because not much is known about the longterm results of surgical treatment of ruptured sinus of Valsalva aneurysm (RSVA), we reviewed our entire 37-year experience with this condition.

METHODS AND RESULTS

From August 1956 through September 1993, 31 patients aged 3 to 54 years (median age, 29 years) underwent surgical correction of RSVA. Aneurysms originated in the right (n = 24) and noncoronary (n = 7) sinuses and entered the right ventricle in 21 patients and the right atrium in 10. Coexistence cardiac lesions included ventricular septal defect (VSD) (n = 16, 15 of which were subarterial) and aortic valve insufficiency (n = 13). There was a highly significant correlation between aortic insufficiency and the presence of an associated subarterial VSD (P < .0001). There was no hospital mortality. One patient (3.2%) died of endocarditis 9 years after subsequent aortic valve replacement; overall survival was 95% at 20 years. Two foreign patients were lost to follow-up after 11 and 13 years, respectively. Follow-up in the remaining 28 survivors extended to 37 years (mean, 25.7 years). Five patients (16.1%) underwent reoperation for aortic valve replacement (n = 3), closure of recurrent fistula (n = 1), and closure of both recurrent fistula and recurrent VSD (n = 1); all had their primary operation before 1976. All patients who had reoperation had right sinus of Valsalva-to-right ventricle fistulas, and 4 had an additional subarterial VSD. Risk of reoperation was higher with right ventricle fistulas than with right atrium fistulas, and this approached statistical significance (P = .06). Risk of reoperation in patients with right ventricle fistulas was lower when an aortotomy (with or without right ventriculotomy) was used during repair (1 of 8, 12.5%) versus right ventriculotomy only (4 of 13, 30.8%), although this did not reach statistical significance (P = .10). Need for reoperation was increased with the presence of a subarterial VSD (P = .08) but not with location of fistula or type of repair (direct suture versus patch). Of 9 patients with mild aortic insufficiency at primary operation, two developed late severe aortic insufficiency necessitating aortic valve replacement at 21 and 31 years, respectively. Twenty-five patients are in New York Heart Association class I, and 3 are in class II.

CONCLUSIONS

Long-term survival after surgical treatment of RSVA is excellent. The risk for recurrent fistula or VSD is minimal in the current era. Late aortic insufficiency is still a risk, especially in right sinus of Valsalva-to-right ventricle fistula with associated subarterial VSD. Repair of RSVA through an aortotomy with or without cardiotomy permits inspection of the aortic root complex and facilitates aortic valve repair; this approach may reduce the incidence of late aortic insufficiency.