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Eur J Cardiothorac Surg 2003;23:650-651
© 2003 Elsevier Science NL

Letter to the Editor

Dissecting aneurysms of the interventricular septum

Department of Cardiothoracic and Vascular Surgery, Cardiothoracic Centre, All India Institute of Medical Sciences, Ansari Nagar, New Delhi 110029, India

Received 30 November 2002; accepted 16 December 2002.

^* Corresponding author. Tel.: +91-11-2619-2337; fax: +91-11-2686-2663
e-mail: shivchoudhary{at}hotmail.com

Key Words: Interventricular septal aneurysm • Aneurysm of sinus of Valsalva • Heart block • Aortic regurgitation

Wu and colleagues have presented an extensive report [1] on this extremely rare entity. Out of six patients, they have resected out the aneurysm sac in four patients, and the resultant defect has been closed with a Dacron patch. Since 1987, we have operated on 14 such patients and part of experience has been published earlier [2]. In our experience, the aneurysm always opened in the right coronary sinus. The aneurysm opening ranged from 4 mm to 2 cm in diameter. In five patients, the aneurysm wall was calcified, and in two, the aneurysm extended up to the apex of the ventricle. Three of our patients had measurable gradients across the right ventricular out flow tract as a result of bulging septal aneurysm.

We repaired all these aneurysms via a transaortic route. The aneurysm mouth was simply closed directly or with a patch and the deformed aortic valve was either repaired or replaced. We did not resect the aneurysm sac and no attempt was made to obliterate its cavity. On follow-up echocardiography, the aneurysm cavity almost disappeared except in the patients with calcified walls. Even in the patients with calcified walls, the cavity became slit-like and thrombosed, and there was no progression. The septal function was almost normal. No extra procedure was carried out for right ventricular outflow tract obstruction. In absence of distending aortic pressure, simple closure of the aneurysm mouth led to collapse of the aneurysm walls and subsequent disappearance of right ventricular obstruction.

Thus we believe, for several reasons, that simple closure of the mouth of the aneurysm is a satisfactory mode of treatment for such entity:

1. The distending high pressure in the aorta is essential for progressive enlargement of the aneurysm, and hence, simple closure of the mouth will halt the process.
   
2. Gradients across the ventricular outflow tract are due to distended and bulging aneurysm. Once the aneurysm collapses, the obstruction will disappear.
   
3. Very often, the wall of the aneurysm is calcified and sometimes the aneurysm sac extends up to the apex of the heart. In such conditions, resection may not only be time consuming but hazardous.
   

Special mention should be made about the aortic valve replacement in presence of a large and/or calcified mouth. In such conditions, if the valve sutures are passed across the mouth of the aneurysm to obliterate its opening, there are high chances that the sutures will be under tension and would give way. This may have happened in cases handled by Wu and colleagues and Bapat and colleagues. In such cases, we always close the aneurysm opening with a prosthetic patch, and if aortic annulus is not spared, the valve sutures are passed through the lower end of the patch.

References

1. Wu Q., Xu J., Shen X., Wang D., Wang S. Surgical treatment of dissecting aneurysm of the interventricular septum. Eur J Cardiothorac Surg 2002;22:517-520.[Abstract/Free Full Text]
2. Choudhary S.K., Bhan A., Reddy S.C.B., Sharma R., Murari V., Airan B., Kumar A.S., Venugopal P. Aneurysm of sinus of Valsalva dissecting into interventricular septum. Ann Thorac Surg 1998;65:735-740.[Abstract/Free Full Text]
3. Bapat V.N., Tendolkar A.G., Khandeparkar J., Dalvi B., Agrawal N., Kulkarni H., Magotra R. Aneurysms of sinus of Valsalva eroding into the interventricular septum: etiopathology and surgical considerations. Eur J Cardiothorac Surg 1997;12:759-765.[Abstract]

This Article Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Shiv Kumar Choudhary Balram Airan Panangipalli Venugopal Permission Requests Citing Articles Citing Articles via Google Scholar Google Scholar Articles by Choudhary, S. K. Articles by Venugopal, P. Search for Related Content PubMed PubMed Citation Articles by Choudhary, S. K. Articles by Venugopal, P. Related Collections Cardiac - other Congenital - acyanotic Great vessels