sinus aneurysm repair

Aortic sinus aneurysm rupture, also known as ruptured sinus of Valsalva aneurysm or sinus of Valsalva fistula, is relatively rare in clinical practice, accounting for 0.31% to 3.56% of congenital heart disease. The incidence rate in humans is five times higher than that in Westerners. It is due to the lack of normal elastic tissue and muscle tissue in the middle layer of the aortic sinus. Under the influence of intra-aortic pressure, the sinus wall gradually becomes thinner and expands outward to form a capsular bulge. , that is, aortic sinus tumor, protruding to the adjacent heart chamber, occasionally the left sinus or the sinus tumor without the coronary sinus protrudes out of the heart. Very few right coronary sinus sinus tumors can protrude into the interventricular septum. When the sinus tumor is not broken, it is generally asymptomatic. When a certain factor, such as strenuous activity or trauma, causes a sudden increase in intra-aortic pressure, the sinus tumor can be broken into the adjacent heart chamber, and acute cardiac insufficiency can occur clinically. The age at which sinus rupture occurs can range from a few years to over 60 years, 80% of patients are between 20 and 40 years old, and there are very few children, and men account for more than two-thirds. Curing disease: Indication 1. A sinus aneurysm that has been ruptured. 2, aortic sinus tumor is not ruptured but combined with ventricular septal defect or aortic regurgitation requires surgical correction. 3, aortic sinus tumor did not rupture, but caused a serious heart rhythm disorder or due to larger tumor sac caused by obvious right ventricular outflow tract obstruction symptoms. 4, simple atrial rupture of the aortic sinus tumor has a sudden rupture caused by acute cardiac tamponade. Contraindications Smaller aortic sinus aneurysms that are unruptured and asymptomatic. Preoperative preparation For patients with incomplete cardiac dysfunction, adequate cardiac, diuretic and vasodilator drugs, as well as bed rest, low-salt diet and intermittent oxygen inhalation should be given before surgery to improve cardiac function and general condition. Surgical procedure Cardiopulmonary bypass and myocardial protection: blood flow is routinely lowered to the nasopharyngeal temperature of 25 to 28 ° C under cardiopulmonary bypass, and the ascending aorta is clamped. In patients with no obvious aortic regurgitation, cold cardioplegia can be infused after the cavity is cut and the tumor is temporarily blocked. For patients with obvious aortic regurgitation, a small incision in the right atrium can be performed, and the cardioplegic solution is retrogradely perfused through the coronary sinus. At the same time, the ice in the pericardial cavity is placed to protect the myocardium. Repair of the sinus sinus tumor is usually performed through a broken heart chamber incision, especially if the ventricular septal defect is diagnosed or not. If the preoperative diagnosis or intraoperative exploration combined with aortic regurgitation, the aortic root incision should be added for examination and repair, that is, double incision path. There are also simple application of transsphenoidal root or conventional transcatheter and aortic root incision for repair of stalacticular sinus tumors. The following are only described by the heart or large vessel incision path. 1. Transsphenoidal sinus tumor repair (1) The midline incision of the chest. Longitudinal sawing open the sternum. The "human" shape is cut into a happy bag and suspended from the sides to the skin. (2) heart incision 1 right ventricular incision: sinus tumor into the right ventricle, especially the right ventricular outflow tract can be used as an outflow tract incision. 2 right atrial incision: the sinus tumor is broken into the right atrium or the right ventricular membrane, you can do a right atrial incision in the parallel atrioventricular groove. 3 left atrial incision: sinus tumor into the left atrium can be done in the left atrial longitudinal incision after the room ditch. It can also be used as a septal incision. (3) After the tumor sac is exposed, the wall of the sinus is cut longitudinally from the tip of the sac, and the inner mouth of the aortic sinus is identified. Then the wall of the sinus is removed, and only 2 mm of the edge is reserved for reinforcement and suturing. (4) Check the presence or absence of lesions in the aortic valve leaf through the sinus tumor and carefully check for the presence or absence of ventricular septal defect. (5) A small number of smaller aortic sinus aneurysms can be repaired with a 4-0 double-ended needle with a padded polyester thread, and intermittent sutures are sutured from the ends of the aortic annulus at the lower edge of the sinus tumor. The aortic wall of the annulus and the upper edge generally requires 3 to 5 needles, and then the second layer of continuous suture is performed after ligation. (6) Aortic sinus tumors generally need to be patched. The size and shape of the patch should be compatible with the aortic sinus defect. Generally, 4-0 polyester thread can be used for round-trip continuous suture or intermittent suture suture. (7) Another method of patch repair is to not cut the tumor capsule and only expand the tip of the capsule. Use a small gasket 4-0 double-needle polyester thread to insert the needle from the neck, and pass it from bottom to top. The annulus and the wall of the healthy aorta are sutured intermittently for one week, and are pierced one by one around the patch, temporarily not tightening the suture. Then use another suture to make a purse-string suture on the wall of the sinus tumor 3 to 5 mm. After ligation, the original needle is used to pass through the middle of the patch, and finally all the sutures are ligated one by one, so that the tumor sac is It is left under the patch and acts as a reinforcement and lining. (8) suture the heart incision, exclude the gas in the heart chamber and the aorta, open the circulation, stop the extracorporeal circulation and end the surgery as usual. 2. Transarterial root sinus tumor repair (1) The mid-thoracic incision, establishment of extracorporeal circulation, blood flow cooling, clamping of the ascending aorta, transcranial sinus or direct perfusion of the cardioplegic solution through the left and right coronary artery opening and placement of ice in the pericardial cavity to protect the myocardium. (2) Aortic root incision: the ascending aorta was cut obliquely or obliquely from 1.5 to 2.0 cm from the aortic annulus, and the lower edge was sutured 2 and the upper edge was sutured with a traction suture, supplemented by eyelids. The hook pulls the aortic incision to reveal the aortic sinus. (3) Check the aortic valve for abnormalities, lesions, and regurgitation. The sinus tumor is found above the aortic annulus, and the tumor sac is pulled from the heart chamber into the aorta, and the wall is removed. The method is the same as above. (4) When the sinus tumor is small, the 4-0 polyester thread can be used to make a round-trip continuous suture or intermittent suture suture in parallel with the aortic annulus. When the sinus tumor is large, the patch is repaired. The size and shape of the patch should be compatible with the aortic wall defect, and sutured continuously with 4-0 polypropylene thread. Care should be taken to fix the suture on the aortic annulus and the healthy aortic wall. (5) When the aortic valve leaf has no significant deformity and lesions and only the valve leaf prolapse and obvious closure, it can be shaped and repaired. The commonly used method is the leaflet folding and suspension method. (6) If the valve has severe deformities and lesions, such as thickening, curling or calcification, and two-valve deformity with insufficiency, etc., which cannot be formed, or if the effect is poor after the formation, aortic valve replacement should be performed immediately. (7) The aortic incision was sutured with a 4-0 polypropylene thread to exclude gas in the heart chamber and the aorta, and the extracorporeal circulation was routinely resuscitated and stopped. 3. Aortic sinus tumor combined with ventricular septal defect repair Atrial sinus aneurysm with ventricular septal defect is the most common, and the latter often directly under the sinus tumor, and this type of aortic sinus tumor with ventricular septal defect is divided into type I (right coronary sinus tumor - right Ventricular septal defect in the superior outflow tract and type II (right coronary sinus tumor - lower ventricular septal defect in the right ventricular outflow tract). Type I aortic sinus aneurysm with ventricular septal defect can also be divided into different levels according to the degree to which the sinus tumor protrudes to the adjacent cardiac chamber. Understanding the above classification will help to understand the design and management of the surgical plan. (1) The chest median incision, establishment of extracorporeal circulation and myocardial protection methods are the same as described above. (2) The right ventricular outflow tract incision is generally used. After clearing the intracardiac lesion, the tumor sac was cut as described above. (3) If the sinus tumor port and the ventricular septal defect are separated by muscle bundles, respectively, if the two are adjacent and are very small, the 3-0 padded polyester thread can be used for direct suture repair. To repair the sinus tumor, it is necessary to sew the aortic annulus and the upper edge of the healthy aortic wall at the lower edge and avoid distortion of the annulus. Then the suture was used to repair the ventricular septal defect, and the sinus tumor was reinforced. (4) The larger sinus tumor mouth patch is repaired together with the ventricular septal defect. The size and shape of the patch should be compatible with the size of the two gaps and the common long axis. It can be used for round-trip continuous suture or with a gasket. 4-0 double-ended needle polyester line intermittent suture to repair ventricular septal defect. The sinus tumor can also be repaired by patch, followed by perfusion of the cardioplegic solution through the aortic root, and the aortic valve closure is observed from the ventricular septal defect to confirm the ventricular septal defect after no reflux. (5) When the aortic valve leaf has no significant deformity and lesions and only the valve leaf prolapse and obvious closure, it can be shaped and repaired. The commonly used method is the leaflet folding and suspension method. (6) If the valve has severe deformities and lesions, such as thickening, curling or calcification, and two-valve deformity with insufficiency, etc., which cannot be formed, or if the effect is poor after the formation, aortic valve replacement should be performed immediately. (7) The aortic incision was sutured with a 4-0 polypropylene thread to exclude gas in the heart chamber and the aorta, and the extracorporeal circulation was routinely resuscitated and stopped. complication The mortality rate of surgery is 0-12%, mostly below 10%. The main cause of death is low cardiac output syndrome and perioperative cardiac arrest. It is related to the need for simultaneous correction of poor cardiac function and cardiac malformation. Other complications include arrhythmia and aortic regurgitation, which is often caused by poor aortic valve formation or poor technique for repairing sinus tumors. In addition to aortic regurgitation, there are a few reports of late atrial aortic sinus tumor recurrence due to incomplete repair. In addition, there are complications associated with concurrent ventricular septal defect repair or aortic valve replacement, such as residual leakage, paravalvular leak, embolization or artificial valve infective endocarditis.