The diagnosis and surgical treatment of ruptured aortic sinus aneurysm Abstract: To summarize the treatment experience of 22 cases of ruptured aortic sinus aneurysm treated surgically in our cardiac surgery department from January 2004 to May 2010. Methods: Of the 22 cases of ruptured aortic sinus aneurysm treated surgically in our hospital, 16 cases had sudden onset, 5 cases had insidious onset, and 1 case had no obvious symptoms and a heart murmur was detected during physical examination. There were 13 cases of combined ventricular septal defect, 9 cases of aortic valve insufficiency and 5 cases of tricuspid valve insufficiency. All patients underwent intracardiac direct visualization repair under general anesthesia with extracorporeal circulation, and were cascade perfused with blood-containing myocardial protective fluid via the aortic root. In all patients, the aortic root and the broken-in cavity were incised and the aortic sinus aneurysm was repaired with a patch, and in 13 patients with combined ventricular septal defects, the same oval patch was used for repair. Two cases of aortic valve replacement and one case of aortic valvuloplasty were performed at the same time. RESULTS: The whole group recovered still smoothly without surgical death, and no complications such as residual shunt occurred at follow-up. At follow-up from 3 months to 46 months, all cardiac functions improved significantly, symptoms disappeared, and they were able to engage in normal study or work. Conclusion: Once diagnosed, aortic sinus aneurysm rupture should be treated by surgery as soon as possible, otherwise there is a possibility of acute heart failure. The aortic sinus aneurysm and the septal defect were repaired with a patch and the same oval patch at the same time. For severe aortic valve insufficiency, aortic valve replacement should be performed at the same time, while mild aortic valve insufficiency can be treated without special treatment. 1 Data and methods 1.1 General data 22 cases in this group, 17 men and 5 women; age 19-42 years. Among them, 16 cases had sudden onset, 5 cases had insidious onset, and the other 1 case had no obvious symptoms, and the heart murmur was found during physical examination. Clinical manifestations included palpitations and shortness of breath after activity in 19 patients, with chest pain in 3 cases. Continuous murmur was heard in 21 cases at the left sternal margin between Ⅱ and Ⅳ ribs, and systolic murmur in 1 case; continuous tremor was felt in 20 cases, and systolic tremor in 5 cases. Peripheral vascular signs were positive in 18 cases. Chest radiographs showed increased pulmonary blood, enlarged heart, and a cardiothoracic ratio of 0.47 to 0.75. Electrocardiograms showed left ventricular hypertrophy in 13 cases, right ventricular hypertrophy in 8 cases, and biventricular hypertrophy in 1 case; incomplete right bundle branch block in 3 cases, and myocardial strain in 5 cases. All cases were preoperatively diagnosed by echocardiography as ruptured aortic sinus aneurysm, including 13 cases with combined ventricular septal defect (VSD), 5 cases with aortic valve insufficiency, and 1 case with tricuspid valve insufficiency. 1.2 Surgical method All patients underwent intracardiac direct vision repair under general anesthesia with extracorporeal circulation, and the aortic root was perfused with blood-containing myocardial protective fluid in a cascade fashion, among which 16 patients underwent direct perfusion of stopping fluid through the ascending aortic heel. The aortic sinus aneurysm was found to have originated from the right coronary sinus in 19 cases, including 15 cases that broke into the right ventricular outflow tract, 2 cases that broke into the right ventricle, and 2 cases that broke into the right atrium; 3 cases that broke into the right atrium from the non-coronary sinus. The diameter of the aortic sinus aneurysm internal orifice was 0.5-2.0 cm, and 13 cases of combined VSD, all of which were of the sub-stem type, located below the anterior part of the sinus aneurysm, with a diameter of 0.6-2.5 cm. There were 5 cases of combined aortic valve insufficiency, including 1 severe, 2 moderate and 2 mild cases; 2 cases of aortic valve replacement and 1 case of aortic valvuloplasty were performed. 2 Results The whole group of patients underwent smooth surgery and there was no surgical death. All cases were followed up for 3 months to 46 months, and the cardiac function improved significantly, the symptoms disappeared, and the patients were able to engage in normal study or work without complications such as residual shunt. 3 Discussion Ruptured aortic sinus aneurysms account for approximately 0.31% to 3.56% of congenital heart disease [1]. Since only the right side of the right coronary sinus and the right side of the noncoronary sinus is associated with the bulbous septum, the majority of aortic sinus aneurysms occur in the right coronary sinus and the noncoronary sinus, and most break into the right ventricle, especially the right ventricular outflow tract [2, 3]. In our group, 86% of the aortic sinus aneurysms occurred in the right coronary sinus and 68% in the right ventricular outflow tract. Aortic sinus aneurysms are often combined with other cardiac malformations, with VSD being the most common, accounting for about 40% to 50% [4]. In our group, 13 patients were combined with VSD, with an incidence of 59%. After rupture of aortic sinus aneurysm, patients may suffer from congestive heart failure quickly, and a few patients may die within a few days after rupture [5, 6]. The incidence of cardiac insufficiency is higher in patients with ruptured aortic sinus aneurysms into the right atrium, and in one of our patients, cardiac function decreased dramatically within a short period of time, presumably related to a greater pressure difference and more fractional flow. Once ruptured aortic sinus aneurysm is diagnosed, early surgery should be pursued in all cases. Hamid et al [9] advocated aortic root incision as the preferred route, which allows simultaneous repair of the VSD and management of the aortic valve lesion, ensuring reliable repair without injury to the aortic valve or annulus and helping to maintain right heart function. At present, simultaneous exploration and repair through both the cardiac cavity and aortic incision is advocated, especially for those who have a clear diagnosis or cannot exclude the presence of aortic regurgitation and large sinus aneurysm endografts, and the aorta must be incised for exploration [10]. All patients in this group underwent repair of aortic sinus aneurysm and VSD via a combined double incision of the aortic root and the heart cavity into which it was broken, and in those with suspected preoperative aortic valve closure insufficiency, aortic valve exploration, shaping or replacement was performed with good results and no complications in one case. The principle of surgery was to precisely close the aortic sinus aneurysm and correct the combined cardiac malformation. In all patients in this group, the aortic sinus aneurysm was repaired with a polyester patch, the base of which was sutured to healthy tissue with a mattress suture with spacers, and the direction of approach was parallel to the longitudinal axis of the aorta to prevent annular distortion. An oval patch is used for simultaneous repair of combined substem VSD. For mild aortic valve incompetence, it can be left untreated; for moderate or more incompetence with good leaflet texture, shaping can be considered; for severe incompetence or significant leaflet lesions, aortic valve replacement is appropriate [10]. In this group, one case of severe aortic valve insufficiency and one case of moderate insufficiency with difficulty in forming were treated with aortic valve replacement, and one case of moderate insufficiency was treated with forming, while the remaining two cases were not given special treatment. Postoperative review of the heart echocardiogram showed disappearance of aortic regurgitation. We believe that repairing the aortic sinus aneurysm with a patch and repairing the VSD with the same patch has a supraglottic effect on mild to moderate prolapse of the aortic valve, thus correcting the aortic valve prolapse and regurgitation.