Download Surgical treatment of dissecting aneurysm of the interventricular

European Journal of Cardio-thoracic Surgery 22 (2002) 517–520
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Surgical treatment of dissecting aneurysm of the interventricular septum
Qingyu Wu*, Jianping Xu, Xiangdong Shen, Dongjin Wang, Shuiyun Wang
Department of Cardiac Surgery, Cardiovascular Institute and Fu Wai Hospital, Chinese Academy of Medical Sciences, Peking Union Medical College,
Beijing 100037, People’s Republic of China
Received 4 August 2001; received in revised form 12 June 2002; accepted 17 June 2002
Abstract
Objective: We reviewed our experience in the surgical treatment of an extremely rare disease, dissecting aneurysm of the interventricular
septum (DAIS). The definition of DAIS is that the interventricular septum is dissected and forms an aneurysm which bulges into both the left
and right ventricles, causing obstruction of both ventricular outflow tracts. It communicates with the aortic root, and may communicate with
the ventricle. It is usually associated with aortic valve regurgitation and aortic annular enlargement. DAIS might also be related to the sinus of
Valsalva aneurysm [Ann Thorac Surg 65 (1998) 735; Ann Thorac Surg 51 (1991) 996; Eur J Thorac Surg 12 (1997) 759]. But in three of our
six patients DAIS was not associated with sinus of Valsalva enlargement or aneurysm. Methods: Between May 1992 and November 2000,
six of 30,701 patients were diagnosed with DAIS, and underwent surgery at Fu Wai Hospital in Beijing. Aortic valve replacement was
performed in five patients, and the perforation at the bottom of the right sinus of Valsalva was repaired in one. The aneurysm was resected
simultaneously in all these patients. Results: One of the six patients required re-operation. And all patients recovered uneventfully without
hospital mortality. Conclusions: DAIS has a progressive course and poor prognosis. Early diagnosis and surgical treatment are mandatory.
q 2002 Elsevier Science B.V. All rights reserved.
Keywords: Interventricular dissecting aneurysm; Cardiac surgery
1. Introduction
Dissecting aneurysm of the interventricular septum
(DAIS) is rare. The aneurysm involves the ventricular
septum, and is usually associated with aortic valve regurgitation and obstruction of the left and right ventricular
outflow tracts [1]. It communicates with the aortic root,
and may communicate with the ventricle. The etiological
factors included enlargement or aneurysm of the sinus of
Valsalva, trauma, bacterial endocarditis, and congenital
myocardial developmental anomaly [2–4]. In this article,
we reviewed our surgical experience in six patients, and
discussed the preoperative diagnosis and surgical technique
of treating this rare disorder.
2. Patients and methods
Six of 30,701 patients were diagnosed with DAIS and
operated on at Fu Wai Hospital from May 1992 to November 2000. There were five males and one female, with ages
ranging from 22 to 50 years. Three patients presented with
* Corresponding author. Fax: 186-10-6833-2376.
E-mail address: [email protected] (Q. Wu).
severe congestive heart failure. One patient had a history of
chest trauma and III A-V block; another had undergone a
remote aortic valve replacement and repair of a ruptured
right sinus of Valsalva aneurysm a year before his present
admission (Table 1). No patients had history of infection
preoperatively.
Electrocardiogram (ECG) revealed complete A-V block
in two patients, requiring a permanent and a temporary
pacemaker, respectively, before surgery. The chest roentgenograms showed increased pulmonary vascular markings
and left ventricle enlargement in five patients. In patient 6,
pulmonary vascular markings decreased due to the obstruction of the right ventricular outflow tract caused by DAIS.
Echocardiography demonstrated the diagnosis of DAIS in
all patients, which was confirmed by angiography (Fig. 1).
Magnetic resonance imaging (MRI) and electron beam
computed tomography were used in three patients.
The operation was performed using hypothermic cardiopulmonary bypass with antegrade cold crystalloid or cold
blood cardioplegia in all six patients. The aneurysmal wall
was resected and the cavity closed (Figs. 2 and 3). In five of
the six patients, a Dacron patch was used to repair the
ventricular septal defect (VSD) created after resection of
DAIS. In the other one patient, DAIS was not resected,
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Q. Wu et al. / European Journal of Cardio-thoracic Surgery 22 (2002) 517–520
Table 1
Preoperative patient data a
No.
Sex
Age (years)
Clinical
NYHA Class
History
1
2
3
4
5
6
Male
Male
Male
Male
Male
Female
39
50
46
22
27
38
CHF
CHF
CHF
Dyspnea, palpitations
Dyspnea
Angina
III
IV
II
III
IV
IV
NS
Chest trauma, TPI
AVR, PPI
NS
NS
NS
a
AVR, aortic valve replacement; CHF, congestive heart failure; NS, nothing special; NYHA, New York Heart Association; PPI, permanent pacemaker
implantation; TPI, temporary pacemaker implantation.
and the VSD was repaired with tissue of DAIS wall. Associated aortic valve replacement was performed in five
patients. In patient 4, the perforation at the bottom of the
right sinus of Valsalva was repaired with an autologous
pericardial patch; in patient 1, aortic periprosthetic leakage
and heart failure were found 2 months postoperatively so
that a reoperation was required. The periprosthetic leak,
with a size of 1 £ 1.8 cm, was found beneath the right coronary cusp area. At the upper part of the dissecting aneurysm,
the aneurysmal wall disrupted from the prosthetic ring and
formed a defect of 2 £ 1.5 cm between two ventricles. After
resection of the whole aneurysmal wall via right ventriculotomy, a large Dacron patch of 4.5 £ 7 cm was used to
repair the defect with three interrupted mattress stitches at
the muscular section of the ventricular septum and with a 4/
0 prolene running suture in the remaining margin. The periprosthetic leak was closed via aortotomy. Operative findings
and techniques are presented in Table 2.
3. Results
There was no operative mortality. In patient 2, a permanent pacemaker was implanted 1 month postoperatively; in
patient 3, sinus rhythm recovered after surgery. All patients
recovered well in the follow-up study (range, 4 months to 8
Fig. 1. DAIS was detected by echocardiography in patient 1 (short axis).
Diastolic (left) and systolic (right). A, aorta; B, DAIS.
years; mean, 3.58 ^ 3.54 years). Chest X-ray plain films
and ECGs indicated no DAIS recurrence. Both prosthetic
and native aortic valves were functioning quite well. The
postoperative cardiac function was NYHA Class I in four
patients, and Class II in two, respectively (Fig. 4).
4. Discussion
DAIS is quite rare. In a literature review, the aneurysm
originated from the right sinus of Valsalva in 40 of the 44
cases of DAIS [1,5,6]. It was believed that ruptured sinus of
Valsalva aneurysm caused DAIS [1,3,5]. But among our six
patients, a coronary sinus of Valsalva aneurysm was found
in three patients (patients 1, 3 and 6). The data of patients 1
and 2 have been reported [7]. In patient 2, the sinus of
Valsalva was normal, but the right coronary cusp was
deformed; in patient 4, a perforation with the diameter of
2 cm was found at the bottom of the right coronary sinus of
Valsalva; in patient 5, the coronary sinus of Valsalva
presented normal, but the aortic annulus of the right coronary sinus and the ventricular septum were disconnected
completely. So we think that ruptured sinus of Valsalva
aneurysm is not the only cause of DAIS; pathological
Fig. 2. DAIS was detected by echocardiography in patient 1 (longitudinal
axis). Diastolic (left) and systolic (right).
Q. Wu et al. / European Journal of Cardio-thoracic Surgery 22 (2002) 517–520
519
Fig. 4. Taking thrombosis (A) from DAIS via right ventriculotomy in
patient 6.
Fig. 3. Cavity of DAIS (B) was shown via right ventriculotomy in patient 4.
The interventricular septum (A) was dissected into two sections.
changes mainly in the ventricular septum should not be
overlooked.
The etiology of this disease still remains obscure. The
coronary sinus of Valsalva aneurysm compresses coronary
arteries, and this may lead to ventricular septal ischemia [8].
Other potential causes include intra-septal myocardial
rupture, hematoma formation and coronary arterial dysplasia [1,6]. In three of our six patients, the sinus of Valsalva
was normal. We believed that the sinus of Valsalva aneurysm was not the only cause of DAIS. The upper part of the
ventricular septum was compressed by coronary sinus of
Valsalva aneurysm, and injured by blood flush, which
might lead to the DAIS formation. Inherited embryological
defects of the aortic annulus and the ventricular septal
myocardium may also contribute to the development of
this pathology [4,9].
DAIS is usually associated with aortic insufficiency of
moderate to severe degree [1]. Among our six patients,
five had severe aortic valve regurgitation, and three had
congestive heart failure. The right aortic valve cusp was
Table 2
Operative findings and techniques a
No.
Approach
Aortic valve
SV
DAIS
Operation
1
AO, RVOT
RCC deformed, severe AI
LSV unruptured 3 £ 5 £ 3 cm
Repair aneurysm of LSV,
close DAIS cavity, AVR
2
AO, RVOT
RCC deformed, severe AI,
annular dilation
Normal
3
AO, RVOT, RA
RSV repaired
4
AO, RVOT, RA
Perivalvular leakage
beneath RCC area
Normal
5 £ 8 £ 6 cm,
communication to AO,
RV
5 £ 4 £ 6 cm,
thrombosis inside,
intima fibrosis
4 £ 5 £ 6 cm
RSV perforation at bottom,
2 cm in diameter
4 £ 5 £ 6 cm
5
AO, RVOT
Normal
4 £ 0.5 £ 3 cm
6
AO, RVOT, PA
AI, RCC discontinued to
the annulus
AI, RCC absent
RSV ruptured
6 £ 8 £ 7 cm, thrombus
Close DAIS cavity, AVR
Resect DAIS, Dacron
patch repair, AVR
Resect DAIS, Dacron and
pericardial patch repair,
tricuspid annularplasty
Resect DAIS, pericardial
patch repair, AVR
Resect DAIS, Dacron
patch repair, AVR
a
AO, aorta; AI, aortic valve insufficiency; AVR, aortic valve replacement; SV, coronary sinus of Valsalva; DAIS, dissecting aneurysm of interventricular
septum; LSV, left coronary sinus of Valsalva; RA, right atrium; RCC, right coronary cusp of aortic valve; RSV, right coronary sinus of Valsalva; RV, right
ventricle; RVOT, right ventricular outflow tract.
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Q. Wu et al. / European Journal of Cardio-thoracic Surgery 22 (2002) 517–520
thickened and deformed in three patients, and was completely absent in one. In addition, annular dilation and annular
cusp disruption also contributed to aortic insufficiency.
Clinical manifestations revealed obstruction of one or both
ventricular outflow tracts, congestive heart failure, arrhythmia, A-V block, etc. The diagnosis of DAIS can be made by
echocardiography. It can detect the site and size of dissecting aneurysm, its relation with the left and right ventricles,
and any abnormality in the aortic valve. Nowadays, color
Doppler can easily show aortic regurgitation, vortex flow in
the DAIS cavity, and communication between DAIS and
left or right ventricle. Aside from echocardiography, MRI
and angiography of the ascending aorta, aortic root, and
ventricles have been proven helpful in the diagnosis of
this disease.
DAIS differs from aortic root abscess both in clinical
manifestation and in pathological changes. Patients with
aortic root abscess often have signs and symptoms of infection over a long period of time. Even when the infection is
controlled and the pus absorbed, the cystic wall becomes
thickened and severely fiberized. The abscess cyst is usually
not so large. DAIS is involved mainly in the ventricular
septum; thrombus, instead of abscess, is usually found
inside the cavity that communicates with the left ventricle.
The objective of the operation in patients with DAIS is to
restore the function of the aortic valve and the integrity of
the ventricular septum, to resect the aneurysm, and to obliterate the obstruction of the left and right ventricular outflow
tracts, so as to improve the heart function. Aortotomy and
right ventriculotomy provide good exposure for resecting
the aneurysm and repairing the VSD after DAIS is resected.
Resecting the DAIS wall should be tailored to each
patient. In four of the six patients, the wall was resected
completely; a Dacron patch was used to repair the VSD
when the aortic valve was replaced, and its adjacent aortic
annulus was firmly attached to the VSD margins, and positioned to the sewing ring of the prosthetic valve. It is undesirable to close the aneurysmal wall directly if the tissue is
edematous and weak, which may lead to perivalvular leakage, communication between two ventricles as well as heart
failure. In patient 2, the DAIS was probably caused by
trauma; the aneurysmal wall was strong enough to keep
the ventricular septum intact after the aneurysmal cavity
was closed with five interrupted and pledgeted mattress
sutures. In patient 4, the DAIS was probably related to the
perforation of the right sinus of Valsalva. Since the ventricular septum did not equally split in this case, the aneurysmal wall was thin on the left side. A good surgical result was
achieved by resecting the aneurysmal wall and repairing the
perforation of the right sinus of Valsalva. Because of the
high pressure in the DAIS cavity and its excessive extension
into the ventricular septum, severe tricuspid insufficiency
and separation between the septal and anterior tricuspid
leaflets developed. Tricuspid insufficiency was repaired
successfully using the DeVega technique.
DAIS is usually associated with aortic valvular abnormalities [1,5], therefore, aortic valve replacement is often
necessary. According to our experience, it is better to put
interrupted pledgeted mattress stitches from the upper part
of the ventricular septum to the aortic annulus via the right
ventriculotomy, utilizing a suitable-sized prosthetic valve.
A temporary pacing should be inserted transvenously, and
temporary pacing wires applied to the epicardium during the
operation. If complete heart block persists, permanent pacemaker implantation is essential 1–2 weeks postoperatively.
DAIS has a progressive course and poor prognosis. All
patients underwent surgery 13 days to 6 months after the
symptoms of DAIS first occurred. Its preoperative complications include obstruction of the left and right ventricular
outflow tracts, arrhythmia, complete heart block, and
communication with the left ventricle, which may result
in intractable heart failure. Early diagnosis and surgical
intervention are mandatory.
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