2-3. Outcome and follow-ups
The patient had no major postoperative complications and was discharged
on postoperative day 24. At follow-up one year after surgery, there was
no aneurysmal lesion on CT, and she was well and had no complications.
Discussion
SVA is a rare congenital or acquired disease. Congenital cases may be
associated with ventricular septal defect or bicuspid aortic valve.
Acquired cases result from infections, such as syphilis, tuberculosis,
and bacterial endocarditis, as well as trauma, aortitis, and connective
tissue diseases, such as Marfan syndrome.1,2,4,5
SVAs mostly originate from the right sinus (65–85% cases); non-sinus
origin is observed in 10–30% cases, and left sinus origin is even
rarer, accounting for less than 5% cases.1,2
Similar to other aneurysms, an unruptured SVA is often asymptomatic;
however, as the aneurysm grows, it causes difficulties in adjacent
structures. When an unruptured left SVA grows, it can cause chest pain
due to acute coronary syndrome caused by the compression of the left
coronary artery by the aneurysm.6–9
Aortic regurgitation caused by aortic annulus enlargement and/or cusp
prolapse is often associated with SVA. A non-ruptured SVA is associated
with aortic regurgitation in 30–50% cases.5
Symptomatic aneurysms, including ruptured ones, are indications for
surgical repair; however, in the case of unruptured and asymptomatic
SVA, the indication and timing of surgery should be determined based on
the evaluation of the risk of SVA, which is calculated by determining
aneurysm size, grade of aortic regurgitation, and risk of thrombus
formation.10,11
Patch closure has been used in many cases for SVAs. Coronary artery
bypass grafting and/or prosthetic valve replacement may be performed
depending on the lesion. Depending on the condition of the aortic root,
such as multiple sinus lesions, aortic root replacement with a
prosthetic valve or a valve-sparing procedure can be
selected.9,10
In addition to the risk of rupture caused by the large saccular aneurysm
protruding into the extracardiac space, the risk of embolism caused by a
thrombus in the aneurysm and the risk of myocardial ischemia caused by
coronary artery compression, we determined that surgery was necessary.
The patient tolerated the operation without any major complications
despite her advanced age. Similar cases of aortic root replacement using
a biological prosthetic valve or a valve-sparing aortic root replacement
have been reported.9,10 In this case, because the
lesion was localized in the left sinus, we decided to reconstruct only
the left sinus with an artificial patch. Coronary artery bypass grafting
was performed to prevent cardiac ischemia.
In aortic regurgitation, if the valve cusps are preserved under normal
conditions, it is important to correct the enlargement of the aortic
valve annulus and the dilated sinotubular junction to control aortic
regurgitation.12,13 In this case, moderate aortic
regurgitation was observed before surgery, and the left aortic annulus
was stretched and unstable owing to the aneurysmal wall defect in the
left sinus, but no major abnormalities were observed in the cusp. The
left sinus and aortic annulus were formed with a patch, and the
sinotubular junction was ring-fixed with a felt strip. Aortic
regurgitation improved with these procedures.
This is a rare case of SVA in an older patient aged >80
years. In a literature review by Nguyen et al. covering reports from
2000 to 2020, there was only one other case of an unruptured SVA in a
patient aged >80 years.4,5 It is preferable
for older patients to have an SVA treated with a less invasive surgical
procedure if the lesion is localized, as in this case.
If aortic enlargement, multiple dilated sinus lesions, marked aortic
annular enlargement or severe aortic regurgitation caused by aortic cusp
lesions had been observed, aortic root replacement with a biological
prosthetic valve would have been performed.
Conclusion
In the extremely rare case of an unruptured giant left SVA in an older
patient, patch repair and coronary artery bypass grafting can be
performed with satisfactory results.
To avoid the risk of acute coronary syndrome, coronary artery bypass
should be performed aggressively if extrinsic compression of the left
coronary artery is obvious. Aortic valve replacement may be avoided by
correcting the aortic annular enlargement and correcting the dilated
sinotubular junction if aortic regurgitation is complicated, as in this
case.