Aneurysms of a single aortic sinus are not uncommon and it may
also involve dilation of the ascending aorta as well. The dilated aortic
sinus usually alters the geometry of the aortic root and patients will
present more often with an aortic insufficiency. Both ruptured and
non-ruptured sinus of valsalva aneurysm (SOVA) can be complicated by
aortic regurgitation, occurring in up to 30% to 50% of patients
[1]. Unruptured SOVA are asymptomatic, but can present as dyspnea,
palpitations, angina or arrhythmia. The treatment options for unruptured
SOVA include aortic root reconstruction or replacement, aortic valve
repair or replacement, Bentall procedure or patch repair of the
SOVA.
Aortic valve resuspension is a widely practised in repair for acute Type
A aortic dissection. This procedure was first described by Walter G
Wolfe from the Duke University, Durham. In his original series, 24 of
the 30 patients with acute aortic dissection had resuspension of the
aortic valve. Further “a woven Dacron® graft was then sutured
beginning at the junction of the left and right coronary cusps. The
graft was fashioned and sutured above the left coronary orifice around
and down to the commissure of the left and non-coronary cusps. The graft
suture line was then extended along the non-coronary cusp and then
around the right coronary artery completing the suture line ”[2].
Three years later, in his updated case series he added, “the
proplapsing portion of the aortic valve (usually the non-coronary cusp)
was resuspended with pledgeted sutures in order to restore competency of
the valve ”. It worth noting that he described a surgical procedure
wherein, the aortic valve was resuspensed and supracoronray aorta was
replaced.
In the recently published article [4], the authors have successfully
performed a “Wolfe Procedure” in a 78 year old female and followed up
the patient for 2 years. Though authors have conscientiously extricated
the option of root repair or replacement, it still raises a few
concerns about the procedure which they have performed. The authors
mention of a “predominant expansion of the non-coronary sinus and
thinning of the wall at the level of FC 22 mm and SV 76, 7x62 mm,
ST-zone 38 mm”. Though not sure of the abbreviations, Figure 1 shows
an enlarged non-coronary aortic sinus. Dilated aortic sinus / annulus
will distort the aortic root leading to aortic insufficiency. It is
surprising that the authors have not mentioned about the status of the
aortic valve and is highly inconceivable that the patient will not be
having any aortic valve insufficieny for such a large aneurysm. The
status of Aortic root aneurysm was detected in preoperative
echocardiogram, while the status of the aortic valve was noted
intraoperatively - “aortic valve leaflets did not close due to
the expansion of the non-coronary sinus” . Though they have not
mentioned about the aortic valve while presenting the case report, but
when opening the discussion, they mention that the, “case report
describes the treatment of an aortic root aneurysm by the replacement of
the aortic valve together with the placement of an interposition graft
with proximal scallop to recreate the non-coronary sinus (i.e., Wolfe
procedure)” . It is not clear whether the authors have replaced the
aortic valve in their patient or they describe in general. In either of
the situations, the procedure describe by Wolfe does not mandate
replacement of aortic valve; it is rather a resuspension of the valve.
They have argued that the Euroscore II of 19.39% is high in regards to
“patient’s age, female sex, the center’s estimated surgical
volume, and the present comorbidities ”. It has to be noted that
‘Center’s surgical volume’ is not a variable in Euroscore II. It should
be further emphasised, that the authors have not any mentioned any
comorbidities of the patients including the left ventricular function
while presenting the case. Earlier studies have reported the
overestimation of surgical risk in septuagenarians and octogenarians by
Euroscore II [5,6,7]. It is a well-known fact that the coronary
artery of elderly patients has to be evaluated before any open heart
surgery; more so when have symptoms of angina. Though the authors
mention that the elderly lady had coronary heart disease with class III
angina pectoris, there is no description of the native coronary arteries
in the manuscript. Atrial fibrillation or arrythimas are well known
presentation symptom for patients with SOVA. This may be due to
compression of the coronary arteries or any chamber(s) of the heart. A
preoperative CT aortagram could have added value in this regard which
the authors have not provided. It is mentioned that there is “dilation
of the ascending, arch, and descending aorta” preoperatively. After the
procedure the size of the aortic arch is 28 mm. It is so intriguing to
know the mechanism of decrease in aortic arch size postoperatively after
the so called “Wolfe Procedure”. As an aortic surgeon it is curious to
note the ‘plunger-top’ of a syringe buried inside the vascular graft in
Figure 3. Not sure why and how it was buried, but it would be of great
value, if the authors could describe the technique of using the same in
detail in a separate manuscript.