Anaesthetic considerations for

Ruptured Sinus of
Valsalva(RSOV)
Presenter :Dr Ankita Singh
Moderator : Dr Arindam Choudhury
 ANATOMY OF AORTIC ROOT
• The aortic root is an ensemble
consisting of distinct entities:
• Aortic valve leaflets
• Leaflet attachments
• Sinuses of valsalva
• Interleaflet trigones
• Sinotubular junction
• Annulus

Charitos E.I et al .Anatomy of the aortic root: implications for valve-sparing [Link] Cardiothorac Surg
2013;2(1):53-56
 CONT..
• Anatomically the aortic valve leaflets
can be divided into three parts:
• The free margin, with a thickened
circular node (nodule of Arantius),
which provides the coaptation area to
the corresponding neighboring valve
leaflets
• The “belly” of the leaflet
• The basal parts of the leaflet or leaflet
attachments
Charitos E.I et al .Anatomy of the aortic root: implications for valve-sparing [Link] Cardiothorac Surg
2013;2(1):53-56
 CONT..
• The distal part of the sinuses toward the ascending aorta together with
the commissures form a tubular structure called the “sinotubular
junction” which separates the aortic root from the ascending aorta
RELATION OF AV BUNDLE WITH AORTIC
ROOT
 SINUS OF VALSALVA ANATOMY
• Sinuses of valsalva are three
focal expansions that form the
walls of the aortic root, limited
proximally by the attachments
of the aortic valve leaflets and
distally by the sino-tubular
junction

M J Underwood et al .The aortic root: structure, function, and surgical reconstruction. Heart 2000;83:376–380
FUNCTION OF SINUS OF VALSALVA
• To prevent occlusion of the coronary
artery ostia during systole
• Forward blood flow completely
opens the aortic leaflets and, at the
same time, curls down into the
sinuses of Valsalva.
• Vortices inside the sinuses prepare
the leaflets to a smooth closure once
the blood flow reverses in diastole
RELATIONS OF AORTIC SINUSES
• RCC:Interventricular septum and the right
ventricular parietal band.
• LCC: Left ventricular free wall and the anterior
mitral valve leaflet.
• NCC : Interatrial septum and the membranous
interventricular septum
• Aneurysm from right coronary sinus usually
ruptures into RV and from noncoronary sinus
into RA. Rupture of left coronary sinus is rare
and may rupture into pericardial cavity.
SINUS OF VALSALVA ANEURYSM
• Sinus of Valsalva aneurysm (SVA) is an
abnormal dilatation of the aortic root
located between the aortic valve annulus
and the sinotubular junction.
• SVA is a rare cardiac anomaly and
comprises up to 3.5% of all congenital
cardiac anomalies.
• The aneurysms originate predominantly
from the right coronary sinus (70%), and
are more prevalent in males and people of
Asian descent
 CONT..
• When viewed from aorta ,the aneurysm
appears as an excavation of the sinus of
Valsalva and protrudes into the
underlying cardiac chamber

Nicholas Kouchoukos ,Eugene Blackstone,Frank Hanley,James Kirklin. Kirklin/Barratt-Boyes Cardiac Surgery

4th Edition. Philadelphia :Saunders; 2013
AETIOPATHOLOGY of ANEURYSMS of
SINUS OF VALSALVA
CONGENITAL ACQUIRED
Connective tissue disorders • Infectious diseases (Endocarditis,
• Klippel Feil syndrome syphilis & tuberculosis)
• Rheumatoid arthritis • Degenerative conditions

• Ehlers-Danhlos syndrome • Atherosclerosis, cystic medial

necrosis
• Marfan’s syndrome
• Injury from deceleration trauma
• Turner’s syndrome
• Iatrogenic pseudoaneurysms-
• Trisomies 13 and 15
Hematoma formation following AVR,
• Loeys-Dietz syndrome
Removal of aortic valve calcifications
• Osteogenesis imperfecta during aortic valve repair/replacement
PATHOLOGY
Absence of normal elastic tissue and media
in and around hinge line and sinuses
↓
Separation of the aortic media of the sinus
from media at the hinge line of the aortic valve cusp
↓
Congenitally weak area gradually enlarges under aortic pressure
↓
Sinus of Valsalva Aneurysm formation and later rupture into one of the
cardiac chambers or surrounding structures
HISTORICAL NOTE
• 1839- 1st described by Hope
 CONT..

• 1840- 1st important paper published by

Thurman
• 1956-1st successful surgical repair with
CPB at Mayo Clinic
• Sakakibara and Konno –studied association
with VSD and AR and were 1ST to provide
a comprehensive classification

Thurman J. On aneurisms, and especially spontaneous varicose aneurisms of the ascending aorta, and sinuses
of Valsalva: with cases. Med Chir Tr 1840; 23:323–384
SAKAKIBARA AND KONNO CLASSIFICATION

S. Liu et al .Angiographic features of ruptured sinus of Valsalva aneurysm: new classification. Journal of
Cardiology 64 (2014) 139–144
ANEURYSM PRESENTS WITH
a) Localized Windsock :
• 75 % patients
• Thin-walled and has 2 parts
• Intracardiac fistulous portion
• A nipple like projection (the low-pressure cardiac chamber with one
or more points of rupture at its apex)
• More common in RCS RV
CONT..
(b) Direct fistulous connection:
• 25% patients
• Between aortic sinus and heart
• More common in NCS Rt atrium

(c) Extracardiac aneurysm :

• Rare
• Typical in LCS origin
 ASSOCIATED LESIONS:
(a) Ventricular septal defect:
• Most common coexisting cardiac anomaly
• 30-50% patients
• More common in RCS origin of aneurysm
• Type of VSD depends on part of RCS involved

Left 1/3rd -juxta-arterial VSD

RCS Central 1/3rd- muscular (outlet portion of septum) / juxtaaortic
VSD
Right 1/3rd-perimembranous VSD
• Hinge line of aortic valve cusp
separates aneurysm from VSD
• Embryologically- defective fusion of
aorto-pulmonary septum with IVS
leading to VSD
• Sakakibara and Konno considered
this a coincidental association rather
than a combined developmental
anomaly
AORTIC VALVE ABNORMALITIES AND
AORTIC REGURGITATION
• VSD venturi effect, lack of support of aortic annulus
↓
aortic cusp prolapse
↓
AR

• VSD not present Bicuspid AoV AR

• Prolonged AR fixed fibrous deformity of prolapsed cusp
• Incidence (20%–30%)
OTHER ANOMALIES
• PULMONARY STENOSIS
• Valvular
• Windsock projection in RVOT (usually)
• Developmental anomaly of RVOT
• COA
• PDA
• ASD
• TOF
• SUBAORTIC STENOSIS
 NATURAL HISTORY OF SINUS OF
VALSALVA ANEURYSM
● Asymptomatic - Incidentally detected
● Timing of Rupture – cant be predicted
● ASOV → protrude into RA → TS/TR
● → into RV → RVOT Obstruction
● Large Sheer mass → CHB & VT
● Rupture - 3rd / 4th decade
● Rupture → Heart Failure & IE - <1 yr→ Death
● VSD+AR → worsen gradually → →
● Prolapse of Cusp reduce Size of VSD → No PAH/inc PVR
● 15 – 20 yrs – Fixed fibrous deformity of prolapsed Cusp
 ANAESTHETIC
CONSIDERATIONS
CLINICAL PRESENTATION
Clinical presentations of Aneurysm of sinus of Valsalva ( AOSV) depends on :

• Size of aneurysm

• The rapidity with which it ruptures

• The cardiac chamber with which it communicates

PRECIPITATING FACTORS (ACUTE
RUPTURE)
• Heavy exertion
• Automobile accidents
• Iatrogenic (cardiac catheterization)
• Infective endocarditis
• Marfan syndrome (predisposing factor)
SYMPTOMS OF RUPTURED SINUS OF
VALSALVA ANEURYSM
• Substernal chest pain
• Abdominal pain
• Mild to severe dyspnea
• Acute heart failure
• Cardiac tamponade
• Hemodynamic compromise and even sudden cardiac death
• Rupture into the interventricular septum has also been reported with
resultant left ventricular outflow tract obstruction

Feldman DN, Roman MJ. Aneurysms of the sinuses of valsalva. Cardiology. 2006;106:73–81.
ON EXAMINATION
General examination-
• F/s/o Marfanoid habitus
–Ectopia Lentis
- High arched palate
- Arm length span (>1.03)
- Arachnodactyly
- Hypermobile joints
- Thumb sign (Steinberg ), wrist sign (Walker-Murdoch)
- Pectus excavatum/carinatum
GENERAL EXAMINATION (CONT..)
• F/s/o Right sided failure
• Pedal edema,
• Engorged neck veins
• Abdominal distension
GENERAL EXAMINATION(CONT..)
• Fever – may be present (due to I.E)
• Tachypnea (due to increase blood flow to lungs)
• Pulse: Bounding pulse (run-off from aorta to low pressure chambers of
heart)
• Radio-femoral delay (if associated with CoA)
• Irregular (if conduction disturbance)
• BP: Wide Pulse Pressure (SBP-DBP)
• Elevated JVP
• Peripheral signs of RSOV/AR

Forehead flushing with heart

beat

Water hammer pulse

SYSTEMIC EXAMINATION

CARDIOVASCULAR EXAMINATION-
• ON INSPECTION- Precordium –hyperkinetic
- Apex beat displaced down and out

• ON PALPATION-Thrill ( Left parasternal border)

- Left parasternal pulsation (ill-sustained, due to RVVO)
- Palpable P2
ON AUSCULTATION
• Continuous murmur– loud, harsh,superficial, entire precordium (best
heard along left lower parasternal area)
• Diastolic accentuation & Systolic suppression (mechanical narrowing
of fistulous tract, ↓flow in sinus during systole)
OTHER SYSTEMS
• RESPIRATORY SYSTEM- B/L crepitations +/-

• ABDOMINAL SYSTEM- ascites+, hepatomegaly (if TR +,pulsatile

liver
D/D FOR CONTINUOUS MURMUR
1. PDA
2. VSD+AR (to and fro murmur)
3. AP WINDOW
4. Surgical shunts
5. AV fistula
6. Collaterals in coarctation of aorta
7. Mammary soufflé (Pregnancy)
8. Venous hum
9. Cruveilhier-baumgarten syndrome
• Tetrad of features- Continuous murmur
+
Elevated JVP
+
Bounding pulse
+
H/O sudden onset chest or epigastric pain
↓
RSOV

• Severity of RSOV- Acute onset of symptoms, f/s/o RHF, tachypnea,

cardiomegaly, palpable P2,↑ JVP, ↑pulse pressure
TREATMENT HISTORY
• Patients often need initial stabilization and control of heart failure
symptoms with diuretics, vasodilators, and inotropes.
INVESTIGSATIONS
BLOOD INVESTIGATIONS
• Hb , TLC, Pc, LFT ,RFT
• Blood culture for infective endocarditis
CHEST X RAY
- Large RSOV → CT ratio>0.5

- LV type apex

- Pul. Venous congestion

- PBF → PA enlargement

- Rarely aneurysmal calcification

Cardiomegaly, right atrial enlargement, dilated pulmonary artery segment,
pulmonary plethora, and pulmonary venous hypertension
 ECG IN RSOV

• P wave - ‘P-pulmonale’ ; if RSOV→ RA

• QRS complex- RBBB or LBBB or CHB ; RSOV → base of septum

• LVH or RVH / RVVO or LVVO

ECHO
• Echocardiography is the main diagnostic tool for the identification of
the aneurysm or rupture of sinus of Valsalva
• Real-time imaging at high temporal and spatial resolution, 3D
advancements of TEE allow delineation of precise cardiac anatomy
specially in intraoperative period.

Jain PK .Is it really ruptured sinus of valsalva? The crucial role of comprehensive transesophageal
echocardiography in clinical [Link] Card Anaesth.2015 Apr-Jun; 18(2): 221–224.
CARDIAC CT SCAN
• CT provides much better spatial resolution of cardiac structures
• It also provides detailed anatomic depiction of Valsalva sinus
aneurysms and surrounding cardiac structures
• The high contrast resolution of CT also may make it possible to
delineate an aortocardiac shunt, if present, and to identify a ruptured
aneurysm by depicting a jet of contrast material extending from the
aneurysm into the adjacent cardiac chamber.
 ECG gated cardiac CT scan showing a tubular jet of contrast (white arrows) is revealed from the anterior base of the
right sinus of Valsalva, into right atrium

Janice et al. Continuous Heart Murmur-Two Cases of Rare Causes and Role of Imaging in Diagnosis OMICS
J Radiology 2013, 2:4
CARDIAC MRI
• Demonstrate anatomy as well
as hemodynamic significance
lesions

Cardiac magnetic resonance imaging shows a ruptured right coronary sinus of Valsalva into the right ventricle.
INDICATIONS FOR INTERVENTION
• Surgical intervention is recommended for a ruptured SOVA and/or a
SOVA with associated intracardiac abnormalities
• Ventricular septal defect
• Significant aortic valve regurgitation.
• An unruptured but symptomatic or enlarging SOVA should also be
considered for surgical repair.

Sinus of Valsalva Aneurysms: Review of the Literature and an Update on [Link] Weinreich
Clin. Cardiol. 38, 3, 185–189 (2015)
CONT..
• Surgical repair should be considered in those with aortic root
aneurysms dimension >5.5 cm, >5 cm in those with bicuspid valves,
>4.5 cm in the setting of connective tissue disease, or a growth rate of
>0.5 cm/year
• Prolonged/severe hemolysis after device placement
• large RSOV with aortic end >12 mm, RSOV with multiple rupture
sites, or those with any suspicion or evidence of infective endocarditis

Parashar NK. Ruptured sinus of valsalva aneurysm: Clinical case presentation and management.J Pract Cardivasc
Sci2017;3:109-14
ANAESTHETIC CHALLENGES/GOALS
• Patients typically will present in high-output congestive heart failure
and often need an adequate preload to maintain tissue perfusion
• In the presence of aortic insufficiency or a large diastolic runoff,
substantial elevation of the systemic vascular resistance is likely to
worsen regurgitation.
• In the absence of severe coronary artery disease, a heart rate that is
slightly above normal should be well tolerated, because tachycardia
shortens diastole, thereby decreasing regurgitant flow.
INDUCTION OF ANAESTHESIA
• Anesthetic techniques that have minimal influence on myocardial
contractility may be preferred to maintain left ventricular function and
prevent further deterioration of the maximally stressed right ventricle.
• A high-dose narcotic technique would have minimal effect on
contractility.
• Judicious use of any anesthetic agent may be acceptable with goals to
maintain contractility and SVR

David Amar et al .Anesthetic Implications of a Ruptured Aneurysm of the Sinus of Valsalva.

Journal of Cardiothoracic and Vascular Anesthtwa, Vol7. No 6 (December). 1993: pp 730-733
INDUCTION OF ANAESTHESIA
• Sudden or unexplained hypotension following induction of anesthesia
may represent decompensation due to heart failure or less likely due to
cardiac tamponade.
• This suspicion may be confirmed by echocardiography while
expeditious sternotomy and initiation of cardiopulmonary bypass are
carried out.
• If a significant pericardial effusion is detected preoperatively, with
signs of tamponade, a cardiac surgeon should be present during
induction, and the patient can be ‘prepped and draped’ prior to
induction.
David Amar et al .Anesthetic Implications of a Ruptured Aneurysm of the Sinus of Valsalva.
Journal of Cardiothoracic and Vascular Anesthtwa, Vol7. No 6 (December). 1993: pp 730-733
INTRA OPERATIVE TEE
● Locate ASOV
● Chamber into which ASOV protruding / rupture
● Severity of AR
● Assess completion of repair of VSD/ aneurysm /AR
ME5C

Mid esophageal 5 chamber view showing left-to-right shunt flow across ventricular septal defect
restricted by septal tricuspid leaflet resembling a windsock deformity
ME AV LAX

Transoesophageal echocardiography shows a ruptured aneurysm of the right coronary sinus with an
obligate left-to-right shunt into the right ventricle, using colour Doppler technique
CARDIOPLEGIA TECHNIQUE
• Antegrade cardioplegia
❖Root (If no AR) NO ROLE IN RSOV
✓Ostial
• Retrograde Cardioplegia
 TREATMENT OPTIONS
● Surgery
– Simple Excision / Plication
– Patch Repair
– AV repair/AVR
– Aortic Root Replacement
● Trans catheter occlusion

Sinus of Valsalva Aneurysm or Fistula:Management & [Link] J Takach et al, Ann of

Thorac Surg 1998;68:1573-7.
SURGICAL APPROACH
• Chamber involved: Preferentially used in patients without significant AR.
• It was thought that by not closing the origin of RSOV, no foreign material is
left in the aortic sinus and the risk of distortion of the aortic sinus was
minimized.
• Transaortic: Exposes the aortic root,competence and the severity of the
pathologic changes of the aortic valve, proper position of RSOV and
coronary ostia.
• Accurate placement of the suture without fear of injury to the coronaries or
the aortic cusps.
• Both:VSD, aortic valve addressed better under vision (not blind), no injury
to adjacent structures, no residual defect. Avoid taking bites on valve tissue
GOALS OF RSOV REPAIR
• Close the RSOV securely, remove the aneurysmal sac and repair any
associated defects without causing heart block or aortic valve
dysfunction.
REAPIR OF SINUS OF VALSALVA
ANEURYSM
• Interrupted suture Patch closure
REAPIR OF SINUS OF VALSALVA
ANEURYSM(Cont..)
• RSOV with VSD
RSOV WITH AR
• Mild AR : No Intervention
• Mod – Sev AR : Aov Repair/AV replacement(Old pt & deformed
cusp / Sev AR – valve not reparable)
Surgeon’s view from the opened aorta into the aneurysm of the right coronary sinus of Valsalva.
UNRUPTURED SINUS OF VALSALVA
ANEURYSM
● Trans Aortic Repair under CPB
● Patch closure of orifice of aneurysm
● Large Aneurysm → AR
– AV repair /AVR
– Root replacement
UNRUPTURED SINUS OF VALSALVA
ANEURYSM (Cont..)
 COMPLICATIONS
● Direct Closure (early in history) → recurrence of Fistula
● Conduction defects (2-3%)(Proximity of Bundle of His) – Pacemaker
● Arrhythmia – VT/VF/Vent Ectopics
● Low Cardiac Output
● Infection (Endocarditis, Para Aortic Abscess)
● Residual VSD
● Patch Dehiscence
● Recurrent Aortic Regurgitation → Congestive Heart Failure
● Prosthetic Valve Endocarditis
● Anticoagulant related Bleeding
 TRANSCATHETER CLOSURE
● Cullen : Rashkind Umbrella – 1994
● Amplatzer Duct Occluder Device

● Transcatheter Gianturco Coil Occlusion

● Indication: Isolated RSOV

● (no infection, AR)

– Orifice size @ aortic side < 12 mm
– Distance bet RSOV & Coronary ostia > 5mm
AMPLATZER DEVICE
Aortic root angiogram showing a ruptured sinus of Valsalva aneurysm forming a windsock deformity
(arrow) into the right side chambers.
Anurag Y et al Rupture of Sinus of Valsalva Aneurysm (Type V Sakakibara Type) Treated by the Amplatzer Pda
Occluder Device. Arc Cas Rep CMed 1(2): 109
COMPLICATIONS OF DEVICE CLOSURE
• Residual Defect
• Device Migration
• Hemolysis
• Encroachment of Aortic leaflets
• AV Conduction defects
• Coronary compromise
• Infection
• Thromboembolism
• Bleeding
IJTCVS 2000; 16:93-101
© 2019 Annals of Cardiac Anaesthesia | Published by Wolters Kluwer - Medknow
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