Treatment of Ruptured Sinus Valsalva Aneurysm With Hemi-Yacoub Remodeling Technique

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This is the case of a 27-year-old female with a past medical history of gastroesophageal reflux disease, cholelithiasis, and postpartum hemorrhage. She presented to the cardiologist’s office with an exacerbation of long-standing palpitations and sporadic postural dizziness that had worsened over the past year. Her preoperative echocardiogram was otherwise unremarkable except for a right coronary cusp to right atrial shunt, as evidenced by color-flow Doppler. Her preoperative computed tomography (CT) scan confirmed the defect between the aortic root and right atrium, consistent with a ruptured sinus of Valsalva. Based on these findings, her cardiologist planned a transcatheter closure using an Amplatzer device. After the implantation, the cardiology team immediately noted severe aortic flow obstruction, as the device displaced the right coronary cusp into the lumen in its diastolic position. Recognizing the need for urgent surgical evaluation, the cardiologist promptly consulted the surgical team. Due to aortic valve dysfunction from the limited movement of the right cusp, the surgeons decided to take her to the operating room within 24 hours due to concern for further valve erosion. 

After the initiation of cardiopulmonary bypass, the heart was arrested. The aorta was transected, revealing the device protruding into the aortic root and sitting on the right coronary cusp, 2 mm above the hinge point and below the origin of the right coronary artery. The cusp looked completely healthy. The right atrium was opened to see the other end of the device, which sat on the anterior and septal tricuspid leaflets, impeding their function.  

The device was transected and removed from the right atrial side, followed by removal from the aortic side. The aortic and right atrial openings of the fistula were inspected, and a saline test was performed to assess tricuspid coaptation. Upon examining  
the right sinus, where the device was initially placed, it was noted that it was positioned below the right coronary artery origin and above the hinge point. The aortic valve appeared bicuspid with a 180-degree commissural orientation, but close examination revealed a rudimentary third cusp toward the noncoronary sinus at the commissure.  

The most definitive way to exclude the fistula was determined to be the replacement of the right sinus using a root remodeling technique, as patch or primary closure would interfere with leaflet function. The right coronary artery was mobilized, and the root was dissected before completely resecting the right sinus. To demonstrate the fistula path, a right-angled clamp was placed from the right atrial side toward the aortic opening. The fistula’s right atrial opening was repaired with a running 4-0 Prolene suture, followed by a saline test, and another 4-0 suture was placed from the aortic side, ensuring that the leaflets were not tethered. 

The root replacement was then performed using the hemi-Yacoub remodeling technique with a 22 mm graft. The procedure started at the nadir of the right sinus of Valsalva and traveled up to the sinotubular junction (STJ) on the right side, taking bites toward the STJ on the other side. Care was taken to ensure that the graft sat well on the inner side of the aortic wall to maintain hemostasis. As the operation progressed toward the junction, bites were taken slightly wider on the graft than on the aorta to allow for sinus bulge formation. Additional interrupted sutures were placed at each side of the graft to anchor the remodeling suture line, and these were tied to the running suture at the STJ.  

The ascending aorta was closed, and the right coronary ostium was reimplanted within the Dacron sinus. Deairing was completed, and the cross-clamp was removed. The heart regained spontaneous sinus rhythm with good biventricular function. The 
postoperative echocardiogram in the four-chamber view showed good biventricular function, and tricuspid valve function was normal. On the short- and long-axis views, there was no evidence of aortic stenosis or regurgitation and no residual fistula. The patient was extubated on postoperative day one, and her postoperative course was uneventful. She was discharged home on postoperative day five. 

References

1. Vekstein AM, Bavaria JE, Desai ND, et al. Selective sinus replacement for aortic root aneurysm: durable approach in selected patients. Ann Thorac Surg. 2023;115(4):954-962. doi:10.1016/j.athoracsur.2022.05.071
2. Urbanski PP, Zhan X, Hijazi H, et al. Selective sinus replacement for aortic root repair in bicuspid aortopathy. J Thorac Cardiovasc Surg. 2024;167(3):908-917.e6. doi:10.1016/j.jtcvs.2022.03.019

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