Surgical reconstruction of giant non-coronary sinus aneurysm using valve-sparing technique

The sinus of Valsalva aneurysm (SVA) is a rare congenital (muscular or elastic deficiency) or acquired (trauma, infection, atherosclerosis) pathological condition. The most common is isolated right sinus aneurism with an incidence of 94%; the non-coronary sinus is affected in 5% of cases, and rarest is an aneurysm of the left coronary sinus, about 1% [1]. Indications for treatment of unruptured SVA are aneurysm dimensions, rapidly increasing in size, prevention of complications (rupture or thrombus formation), symptoms and clinical presentation [2]. The literature describes different surgical strategies for the treatment of this pathology. 
We performed surgical reconstruction of giant non-coronary sinus of Valsalva aneurysm using the valve-sparing procedure (David procedure). 
The 55-year-old woman was admitted to the hospital due to palpitation, dyspnea and fatigue. The patient has no history of cardiovascular diseases. Transthoracic echocardiography examination revealed a huge aneurysm (45 40 mm) of the non-coronary sinus of Valsalva. An aneurysm sac compressed the right atrium and superior vena cava. The right-side filling pressure was elevated. The superior vena cava was dilated 28 mm, with an increased diastolic flow gradient of 9/5 mm Hg. The ascending aorta was 45 mm with moderate aortic valve regurgitation. The ejection fraction and dimensions of the heart were in the reference range. An additional computed tomography scan revealed a saccular aneurysm 45  40 mm of the non-coronary sinus of Valsalva and a smaller aneurysm of the right coronary sinus (Figures 1 A–C). 
The surgical procedure was performed through median sternotomy. A giant aneurysm of the non-coronary sinus of Valsalva was detected. The right atrium was significantly compressed by an aneurysm sac (Figure 2 A). Cardiopulmonary bypass was established by ascending aorta and bicaval venous cannulation. Incision of the ascending aorta near the sinotubular junction was performed, and the aneurysm cavity and aortic valve were inspected (Figure 2 B). Due to the normal morphology of all three valve leaflets, we decided to perform the valve-sparing aortic root replacement procedure (David procedure). The preparation of the non-coronary sinus from the right atrium was challenging due to the frailty of the atrium tissue, and the damaged atrial wall was reconstructed with an autologous pericardial patch. Resection of the aneurysm and right and left coronary sinuses was...


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