Sinus of valsalva aneurysm from left sinus: value of angioscopic view of a 3-dimensional computed tomographic angiography.

A 57-year-old man was referred for exertional chest pain and a mediastinal mass. Computed tomographic angiography (CTA) revealed a huge aneurysm arising from the left sinus of Valsalva (Figure 1, Video I in the online-only Data Supplement). The opening of aneurysm was 18 mm in its largest diameter. Because the left coronary arteries were stretched and narrowed, the chest pain was considered to be caused by the aneurysm. The right coronary artery and other cardiac structures were normal. In transthoracic echocardiography, there was mild aortic and mitral regurgitation. The transesophageal echocardiography also showed competent aortic valve and aneurysm. However, it was not clear whether the aortic valve annulus was intact or not (Video II in the online-only Data Supplement). To understand the anatomy of aortic root complex, including aortic valve, coronary ostium, and the aneurysm, we reconstructed the 3-dimensional images showing the inside of aorta, hence called an angioscopic view. The CTA angioscopic image confirmed that there was no involvement of the aortic valve or the left coronary ostium by the aneurysm (Figure 2). The image also indicated how much tissue was present between the opening of aneurysm and coronary ostium. Thus, we were able to plan surgical internal closure of the sinus of Valsalva aneurysm rather than aortic root replacement. Surgery was performed by median sternotomy, cardiopulmonary bypass, and cardioplegic arrest. The operative findings were consistent with the CTA angioscopic image, and there was sufficient room for stitches (Figure 3). The aneurysm was opened and plicated. The thrombus was removed only partially to prevent a kink of the coronary artery. The sinus defect was closed with a piece of bovine pericardium. Great care was taken so as to not interfere with the left coronary ostium. The aortic valve commissuroplasty was performed to decrease aortic regurgitation. The recovery was uneventful. In CTA before discharge, the aneurysm was completely thrombosed and had decreased in size from 60 to 40 mm. The coronary arteries were less stretched and less narrowed (Figure 4). The echocardiography showed only trivial aortic and mitral regurgitation. The patient did not have any chest pain 3 months after surgery.