High-Resolution CT-Based Virtual Simulation of an Unruptured Sinus of Valsalva Aneurysm for Aortic Root...

Valve-sparing aortic root replacement (VSRR) for sinus of Valsalva aneurysm (SVA) is rarely reported due to technical challenges. In this case report, high-resolution CT data were used for 3D computer graphics (3DCG) visualization and precise measurement of aortic root geometry, facilitating VSRR in a patient with a markedly disproportionate, unruptured SVA.

A 36-year-old female experienced heart failure at delivery. Echocardiography revealed an SVA involving a dilated noncoronary sinus (NCS) (43 mm) extending over the right atrium, a dilated sinotubular junction, and moderate aortic regurgitation (AR). To assess the feasibility of VSRR, electrocardiogram-gated CT data were analyzed in 2 ways. First, multiplanar reconstruction of CT images allowed measurement of the virtual basal ring area (566.6 mm², corresponding to 26.9 mm), cusp angles (left-coronary, right-coronary, and noncoronary cusps: 110°, 117°, and 133°, respectively), and commissural heights (16.2, 6.3, and 19.6 mm at the non-left, left-right, and right-non intercusp commissures, respectively). Second, high-quality 3DCG images were generated to simulate the surgeon's intraoperative view. VSRR using the reimplantation technique was performed. Under an aortic cross-clamp, the SVA wall was incised, leaving a 5-mm margin above the annulus. The subvalvular tissue beneath the SVA appeared thin and fragile. A 32-mm straight graft was plicated to 29 mm at the bottom for subvalvular fixation. For the NCS, additional running sutures were applied between the graft's bottom skirt and the remnant SVA wall to secure hemostasis. Commissures were fixed at predicted heights based on CT measurements; one commissure required a 1-mm adjustment using the water test. Supravalvular aortic rims were then secured inside the graft with 4-0 monofilament running sutures. No additional cusp repair was necessary. The patient was weaned from cardiopulmonary bypass smoothly, and her postoperative course was uneventful. Transthoracic echocardiography at discharge showed mild AR, which remained stable after 1 year.

This case demonstrates successful aortic root reimplantation for an unruptured SVA. CT-based aortic root visualization and measurement provided clear virtual images, facilitating surgical planning and increasing confidence in performing valve-sparing procedures for SVAs with unusual anatomy.