P036: SINUS OF VALSALVA ANUERYSM AS A RARE CAUSE OF PERIOPERATIVE STROKE: WHEN TO PROCEED WITH CARDIO-PULMONARY BYPASS
Tarrah A Folley, MD, Opal Raj, MD, Ahmad Zeeshan, MD; Cleveland Clinic Florida
Intro: We present a case of Sinus of Valsalva aneurysm (SVA) as a rare cause of cerebrovascular infarcts and the perioperative indications for cardiopulmonary bypass and full heparinization after an acute stroke.
Background: Patient is a 79 year old female with a past medical history significant for mitral valve prolapse, hypertension, and hypothyroidism who was found to have new onset seizures at home. During her hospitalization, workup included CT head, stress myocardial perfusion study, and coronary angiogram all of which returned negative findings. A noncoronary Sinus of Valsalva aneurysm was incidentally discovered with an aneurysmal neck width of 1.9 cm and height of 2.0 cm and the entire Sinus of Valsalva measuring in at 4.7 cm. Valve sparing, non-coronary SVA aneurysm patch repair was recommended. A week prior to surgery, an MRI was performed demonstrating several, chronic, small, lacunar and cerebellar infarcts as well as an acute small vessel infarct of the inferior left cerebellum. Neurology was consulted for surgical clearance regarding full anticoagulation in the setting of an acute stroke and changes to cerebral autoregulation that may occur. Neurology cleared the patient for surgery and she had a valve sparing, non-coronary SVA patch repair. Patient was fully heparinized and tolerated bypass with no intraoperative complications. The patient had an uncomplicated postoperative course, and was monitored in the surgical ICU until she was discharged on postoperative day six.
Discussion: SVA is a weakness of the elastic lamina at the junction of the aortic media and the annulus fibrosis and may be congenital or acquired. It usually presents as a incidental finding on cardiac imaging or ultrasound, and is present in about 0.09% of the general population. SVA commonly arise from the right coronary (90%), noncoronary (8%), or rarely left (2%). The symptoms of SVA are variable and range from asymptomatic to a cardiac emergency. SVA’s account for about 0.15-1.5% of cardiopulmonary operations in the US. Presenting symptoms commonly include dyspnea, angina, conduction abnormalities, syncope, coronary infarction, congestive failure or cardiac ischemia. In a review of 53 cases between 1985-2000 none of them presented with neurological symptoms or stroke. We presume that this noncoronary SVA was an embolic source of stroke in our particular case. The treatment of SVA is often surgical but the question lies in when to proceed to the OR after stroke.
Conclusion: SVA presenting with altered mental status is very rare. MRI should be performed when SVA is incidentally discovered accompanying acute altered mental status changes. It is likely that the SVA was an embolic source of stroke in the case of our patient. There are no defined guidelines for proceeding with cardiac surgery after acute ischemic stroke. Current recommendations are limited to stroke and noncardiac surgery.