Discussion

Aneurysm of the sinus of Valsalva is a rare congenital cardiac defect.Reference Malik, Babar, Khalil, Shah and Laiq ⁵ Aneurysmal dilatation of the sinus of Valsalva occurs when the media of the aortic wall is defective. The right sinus of Valsalva is most commonly involved (in approximately 65–85% of cases), followed by the non-coronary sinus. Involvement of the left sinus is least common. The dilatation and aneurysmal prolapse of a coronary sinus is a slow process occurring over years and it has been described with other diseases such as ventricular septal defects, bacterial endocarditis, atherosclerosis, and chest trauma.Reference Helmy, Shaaban, Chaikouni and Hajar ^{2 ,} Reference Tipoo Sultan, Basir and Fatimi ⁶

Rupture of the sinus of Valsalva, due to thinning of its wall, can occur into any chamber. A right sinus of Valsalva aneurysm can rupture into the right ventricle,Reference Malik, Babar, Khalil, Shah and Laiq ^{5 ,} Reference Lakoumentas, Bonou and Brili ⁷ and a non-coronary sinus of Valsalva aneurysm can rupture into the right atriumReference López-Velarde, Avila-Vanzzini, López-Velarde, Dabaghi-Richerand, López-Soriano and Espinola-Zavaleta ⁸ and rarely into the left-sided chambers, pulmonary artery, or pericardium. Rupture of a sinus of Valsalva aneurysm into the interventricular septum can also be described as a dissecting aneurysm into the interventricular septum. It is very rare and is usually associated with aortic valve regurgitation. Owing to its dissecting nature, it can cause conduction abnormalitiesReference Abdel Hay ³ or rupture into the ventricular cavity causing congestive heart failure. Our patient also developed a cystic aneurysmal cavity in the interventricular septum communicating with the right sinus of Valsalva that collapsed in systole and filled with blood during diastole. Preoperative conduction abnormalities were not seen in our case, as have been reported by others.Reference Helmy, Shaaban, Chaikouni and Hajar ^{2 ,} Reference Abdel Hay ³

These patients have a potential risk for rupture of the sinus of Valsalva aneurysm, leading to the development of congestive heart failure, endocarditis, conduction abnormalities, stroke, and sudden death, justifying surgical repair even in asymptomatic patients.Reference Malik, Babar, Khalil, Shah and Laiq ⁵ Surgical management depends on the extent of involvement. Repair of the aortic leaflet may be successful if it is not overtly distorted; however, if there is significant fibrosis and distortion, the aortic valve may require replacement. The condition is usually associated with aortic insufficiency, which was mild in our case. The aortic leaflet was not badly distorted and was successfully repaired with bovine pericardium. Distortion of the mitral valve can also occur, as described by Tomar et al,Reference Tomar, Radhakrishnan, Kausha and Iyer ⁹ requiring repair or replacement. Our patient had moderate mitral regurgitation, and the valve was successfully repaired.

The most frequently reported complication of surgery is a conduction abnormality due to suture injury. Several techniques have been described to avoid the conduction bundles during surgery.Reference Lee, Lee, Hsiung, Wei, Chuang and Chang ^{4 ,} Reference Choudhary, Bhan and Reddy ¹⁰ In the case of aortic valve replacement, one technique includes careful placement of sutures in the region of the right coronary artery, using an “outside-in” suture method, wherein the sutures start from outside the aorta and then extend up to the aortic ring. In our case, a continuous polypropylene suture was placed, bringing the defect edges together. The “windsock” was included in the suture through the aortic valve orifice. No postoperative conduction abnormality was observed.