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Aneurysm of the sinus of Valsalva
Journal of Thoracic and Cardiovascular
16
Surgery
Aneurysm of the sinus of Valsalva Viking Olov Björk, M.D., and Lars Björk, M.D., ., Uppsala, Sweden
x v n e u r y s m of the sinus of Valsalva is a complication of acute bacterial endocarditis. The inflammation will cause necrosis of portions of the cusp and the aortic diastolic pressure exerted upon the sinus of Valsalva may lead to an outpouching which can rupture. We have encountered 3 cases of erosive aneurysm combined with aortic in sufficiency from prolapsing and perforated cusps, and 2 cases of ruptured aneurysm— one into the right ventricle and one into the left ventricle. Material Aortic insufficiency in association with erosive aneurysm of the sinus of Valsalva presents special problems during operation. CASE 1. A 23-year-old woman had septic endo carditis 5 years before admission to the hospital. During the previous 5 years there had been in creasing symptoms of attacks of tachycardia dur ing slight exercise as well as signs of decompensa tion. Preoperative investigation showed a harsh systolic-diastolic murmur with maximum intensity at the left second intercostal space. Blood pressure in the left ventricle was 140/10 mm. Hg and in the ascending aorta was 150/45. There was a sig nificant hammer pulse. The heart was already sig nificantly enlarged to 800 ml. per square meter of body surface area, with a total volume of 1,260 ml. Left ventricular angiogram showed a huge left ventricle with a maximal diastolic volume of 530 ml., but with good contractions. In relation to the noncoronary cusp, a bulging aneurysm of the sinus Valsalva was demonstrated (Fig. 1, A). Thoracic aortography showed a nearly maximal aortic insufficiency. Operation was performed on Feb. 15, 1961. The patient was explored by way From the University Hospital, Uppsala, Sweden. Received for publication Nov. 14, 1964.
of a median sternotomy. During palpation in the right atrium, a thin-walled protruding aneurysm of the sinus of Valsalva into the right atrium, as large as the phalanx of the thumb, was pal pated. The patient was connected to the heartlung machine. When the aorta was opened, 3 prolapsing cusps were observed with a septic perforation, 10 mm. in diameter, in the right aortic cusp, a smaller (4 mm.) perforation in the left aortic cusp, and a huge aneurysm of the sinus of Valsalva in the bottom in the noncoronary cusp (Fig. 1, B). The cusps were excised and a No. 12 Starr-Edwards ball-valve prosthesis was inserted in such a way so as to occlude the opening to the aneurysm (Fig. 1, C and £>). The patient made an uneventful recovery. The gradient over the ballvalve prosthesis was 13 mm. Hg. One year later the heart had diminished to 440 ml., and 3 years after operation the heart was 430 ml. per square meter of body surface area. At the examination made 10 months after operation, there was a rest ing gradient of 15 mm. Hg over the ball-valve prosthesis at a cardiac output of 8.9 L. per min ute. At the workload test of 400 kilopondmeter per minute, when the cardiac output was 13 L., the gradient increased to 35 mm. Hg systolic. Aortography showed no remaining aneurysm of the sinus of Valsalva (Fig. 1, E). CASE 2. A 25-year-old man had had septic endo carditis 2 years before admission to the hospital at which time a severe aortic insufficiency was verified in a huge heart of 820 ml. per square meter of body surface area, with a total volume of 1,600 ml. During angiography, the left ventric ular diastolic volume was 740 ml. and the sys tolic volume was 210 ml. Thoracic aortography showed an almost free aortic régurgitation (Fig. 2, A). At operation on Jan. 28, 1964, the non coronary aortic cusp was found to have a septic perforation of 15 mm. in diameter. At the base of the right aortic cusp below the right coronary artery there was a small erosive aneurysm, 5 mm. in diameter (Fig. 2, B). The cusp was excised and a No. 11 ball-valve prosthesis was introduced. The sutures also occluded the small erosive aneu-
Volume 50 Number 1
Aneurysm of sinus of Valsalva
17
July, 1965
Fig. \A. Case 1. Thoracic aortography. Patient in left anterior oblique position. Severe aortic in sufficiency with complete filling of left ventricle (LV). Aneurysm with a diameter of 1 cm. from the noncoronary sinus (arrows).
m φ"*% m m^ß^^^^^^s^^;^ Fig. IB. Diagram of the findings at operation—a large perforation in the right aortic cusp (R), and a small perforation in the left (L), as well as a thumb-sized aneurysm of the noncoronary sinus of Valsalva.
Fig. 1. C and D. Diagram of how the sutures were placed in order to occlude the opening of the aneurysm of the sinus of Valsalva.
18
Björk and Björk
Journal of Thoracic and Cardiovascular Surgery
Fig. IE. Aortogram of same patient made 10 months postoperatively. Starr-Edwards prosthesis in the aorta. No aortic insufficiency. The coronary sinus aneurysm is obliterated.
Fig. 2A. Case 2. Thoracic aortography demonstrates aortic insufficiency. On this early film in the series the leakage through a perforation in the noncoronary cusp can be seen (arrows).
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Aneurysm of sinus of Valsalva
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July, 1965
rysm. The patient died in circulatory failure 1 week after the operation because of myocardial infarction. CASE 3. A 40-year-old man with polyarthritis had severe aortic insufficiency with a huge heart of 1,710 ml. total volume, corresponding to 940 ml. per square meter of body surface area. Aortography showed that contrast medium injected into the aorta was found with the same density in the left ventricle which also indicated a severe aortic insufficiency. There was also a small aneu rysm in the right sinus of Valsalva (Fig. 3, A). The diastolic volume of the left ventricle was 740 ml. and the systolic volume 280 ml. In other words there was a very large volume of residual blood in the left ventricle. Left ventricular pres sure was 110/20 mm. Hg when the aortic pres sure was 155/60. When the patient was connected to the heart-lung machine and the aorta was opened, 3 prolapsing cusps were found as well as a small erosion aneurysm, as large as the end of a fingertip, at the base of the right aortic cusp (Fig. 3, B). A No. 11 Starr-Edwards ballvalve prosthesis was inserted and the sutures were placed so as to occlude the aneurysm of the sinus of Valsalva. Immediately after the operation the patient was found to have a diastolic murmur which increased in intensity, although the heart diminished in size from 920 ml. to 580 ml. per square meter. Repeated aortography demonstrated a leakage of contrast medium through a slitformed opening at the side of the valve prosthesis (Fig. 3, C ) . A reoperation was therefore per formed 7 months later at which time two holes were found at the side of the ball-valve prosthesis (10 and 3 mm., respectively). Both holes were
Fig. IB. Diagram demonstrates a small erosive aneurysm of 5 mm. in diameter at the base of the right coronary artery as well as a 15 mm. septic perforation in the noncoronary cusp (NC).
Fig. 3/4. Case 3. Thoracic aortography, lateral view. Free aortic insufficiency with complete filling of left ventricle (LV). Aneurysm of the sinus of Valsalva originates from the right coronary sinus (arrow).
Fig. 3B. Diagram demonstrates an erosion aneu rysm, 10 mm. in size, at the base of the right aortic cusp, as well as three prolapsing cusps.
Journal of
2 0 Björk and Björk
Thoracic and Cardiovascular Surgery
uneventful recovery. The recurrent leakage around the prosthesis could not be directly as cribed to the aneurysm of the sinus of Valsalva as the lesion was found on each side of the site of this aneurysm.
Fig. 3C. Aortogram of the same patient made postoperatively. The Starr-Edwards prosthesis is competent. Leakage through a small opening lateral to the prosthesis (arrow). Aneurysm of the sinus of Valsalva is obliterated. closed by mattress sutures over a strip of Dacron over to the Teflon cuff of the ball-valve prosthesis. The increased flow due to the insufficiency caused a systolic gradient of 60 mm. Hg over the aortic ostium. This gradient was completely abolished after closure of the holes. The patient made an
CASE 4. A 29-year-old man was found to have a continuous heart murmur when he was 10 years of age. He did not come for medical treatment until the age of 29 years when there was a con tinuous murmur and thrill and a large heart of 710 ml. per square meter of body surface area. There was moderate right hypertension and a left-to-right shunt to the right ventricle. Satura tion in the superior vena cava was 74 per cent, in the right atrium 71, right ventricle 95, and the pulmonary artery 88. The systolic pulmonary ar tery pressure was 40 mm. Hg. Thoracic aortography verified an aneurysm of the sinus of Val salva, ruptured into the right ventricle. At the operation in May, 1960, the patient was connected to the heart-lung machine and right ventriculotomy exposed a finger-sized aneurysm in the right ventricle originating from the right sinus of Val salva. The aneurysm had two perforations in the wall. It was excised and closed by direct suture. Immediately adjacent to the aneurysm was a 7 by 3 mm. ventricular septal defect which was also closed by a row of isolated sutures (Fig. 4). The patient made an uneventful recovery and 1 year later no shunt could be found at right heart catheterization. The heart had diminished from 800 to 610 ml. per square meter of body surface area. CASE 5. An 8-year-old boy had been admitted to the hospital because of a congenital aortic in sufficiency. The heart had rapidly increased in
^M\
«pif
Fig. 4. Case 4. Diagram demonstrates aneurysm of the sinus of Valsalva from the right sinus of Valsalva prolapsing into the right ventricle which has two perforations in the wall. Adjacent to the aneurysm was a 7 by 3 mm. ventricular septal defect which was also closed by a row of isolated sutures.
Volume 50 Number 1
Aneurysm
of sinus of Valsalva
2 1
July, 1965
size to 850 ml. per square meter of body sur face area. The patient was operated upon on Dec. 4, 1963. When the patient was connected to the heart-lung machine and the aorta was opened, it was found that there was a large aneurysm of the right sinus of Valsalva with a 10 to 20 mm. perforation in the bottom of the aortic cusp open ing into the left ventricle. The hole was sur rounded by thick fibrotic edges. The noncoronary cusp, however, was prolapsing and also caused aortic insufficiency. As the patient was a child of 8 years of age the hole at the bottom of the right cusp into the left ventricle was closed by a row of direct sutures. The patient withstood the operation well and was much improved. Al though some aortic insufficiency remains, the heart has significantly diminished in size. Within 2 weeks after operation, it had decreased from 850 to 740 ml. per square meter of body surface area.
Discussion In cases of the combination of aortic insufficiency and an erosion aneurysm of the sinus of Valsalva, a septic origin is obvious. Also, in our patient with the aneurysm that ruptured into the left ventricle, it seems obvious that an infection has been the cause of the aneurysm. In the other case of a bulging aneurysm of the sinus of Valsalva into the right ventricle, a septic cause of the aneurysm is probable, although not as obvious. In cases of erosion aneurysm of the sinus of Valsalva in connection with aortic valvular insufficiency, it is most im portant to try to obliterate the aneurysm of the sinus of Valsalva with the sutures fixing the prosthesis in the aortic orifice. If only one edge of the aneurysm will fix the prosthesis, there is a great risk of the su tures cutting through. If, however, the sutures in the root of the aorta are buffered with Teflon pearls and the mattress sutures take bites of the wall on both sides of the aneurysm this will be avoided. The collar of the prosthesis will then reinforce the aortic wall and prevent the sutures from cutting through. In the first case, in which a rather large aneurysm of the sinus of Valsalva bulging into the right atrium was excluded in the way just described by the
sutures fixing the ball-valve prosthesis, no aneurysm could be found at the angio graphie examination at follow-up. In Case 3, a recurrent aortic insufficiency at the side of the Starr valve prosthesis was found. However, the site where the sutures had cut through was not in the base of the right aortic cusp where an aneurysm had been obliterated; it was, instead, at the site of the commissures where too much tension had caused the sutures to cut through. These two observations prove that it is possible to obliterate an erosion aneurysm of the sinus of Valsalva with the same su tures that secure the ball-valve prosthesis in the aortic orifice. In the case of ruptured aneurysm of the sinus of Valsalva, not asso ciated with aortic insufficiency, the aneurysm is excised and closed by direct suture. Summary Diagnostic and therapeutic aspects in 3 cases of erosion aneurysm of the sinus of Valsalva in association with aortic insuffi ciency are discussed, as well as those in 2 cases of ruptured aneurysm of the sinus of Valsalva. REFERENCES 1 Aletras, H., Björk, V. O., Cullhed, I., and Intonti, F.: Ruptured Congenital Aneurysm of the Sinus of Valsalva With Ventricular Septal Defect, Thorax 18: 127, 1963. 2 Björk, V. O.: Aortic Valve Replacement, Thorax 19: 369, 1964. 3 Harken, D. E„ Soroff, H. S., Taylor, W. J., Lefefnine, A. A., Gupta, S. K., and Lunzer, S.: Partial and Complete Prostheses in Aortic In sufficiency, J. THORACIC & CARDIOVAS. SURG. 40:
744, 1960. 4 Kjellberg, S. R., Mannheimer, E., Rudhe, U., and Jonsson, B.: Diagnosis of Congenital Heart Disease, ed. 2, Chicago, 1959, Year Book Pub lishers, Inc. 5 Starr, A., Edwards, M. L., McCord, C. W., and Griswold, H. E.: Aortic Replacement: Clinical Experience With a Semi-Rigid Ball-Valve Pros thesis, Circulation 27: 779, 1963.
16
Surgery
Aneurysm of the sinus of Valsalva Viking Olov Björk, M.D., and Lars Björk, M.D., ., Uppsala, Sweden
x v n e u r y s m of the sinus of Valsalva is a complication of acute bacterial endocarditis. The inflammation will cause necrosis of portions of the cusp and the aortic diastolic pressure exerted upon the sinus of Valsalva may lead to an outpouching which can rupture. We have encountered 3 cases of erosive aneurysm combined with aortic in sufficiency from prolapsing and perforated cusps, and 2 cases of ruptured aneurysm— one into the right ventricle and one into the left ventricle. Material Aortic insufficiency in association with erosive aneurysm of the sinus of Valsalva presents special problems during operation. CASE 1. A 23-year-old woman had septic endo carditis 5 years before admission to the hospital. During the previous 5 years there had been in creasing symptoms of attacks of tachycardia dur ing slight exercise as well as signs of decompensa tion. Preoperative investigation showed a harsh systolic-diastolic murmur with maximum intensity at the left second intercostal space. Blood pressure in the left ventricle was 140/10 mm. Hg and in the ascending aorta was 150/45. There was a sig nificant hammer pulse. The heart was already sig nificantly enlarged to 800 ml. per square meter of body surface area, with a total volume of 1,260 ml. Left ventricular angiogram showed a huge left ventricle with a maximal diastolic volume of 530 ml., but with good contractions. In relation to the noncoronary cusp, a bulging aneurysm of the sinus Valsalva was demonstrated (Fig. 1, A). Thoracic aortography showed a nearly maximal aortic insufficiency. Operation was performed on Feb. 15, 1961. The patient was explored by way From the University Hospital, Uppsala, Sweden. Received for publication Nov. 14, 1964.
of a median sternotomy. During palpation in the right atrium, a thin-walled protruding aneurysm of the sinus of Valsalva into the right atrium, as large as the phalanx of the thumb, was pal pated. The patient was connected to the heartlung machine. When the aorta was opened, 3 prolapsing cusps were observed with a septic perforation, 10 mm. in diameter, in the right aortic cusp, a smaller (4 mm.) perforation in the left aortic cusp, and a huge aneurysm of the sinus of Valsalva in the bottom in the noncoronary cusp (Fig. 1, B). The cusps were excised and a No. 12 Starr-Edwards ball-valve prosthesis was inserted in such a way so as to occlude the opening to the aneurysm (Fig. 1, C and £>). The patient made an uneventful recovery. The gradient over the ballvalve prosthesis was 13 mm. Hg. One year later the heart had diminished to 440 ml., and 3 years after operation the heart was 430 ml. per square meter of body surface area. At the examination made 10 months after operation, there was a rest ing gradient of 15 mm. Hg over the ball-valve prosthesis at a cardiac output of 8.9 L. per min ute. At the workload test of 400 kilopondmeter per minute, when the cardiac output was 13 L., the gradient increased to 35 mm. Hg systolic. Aortography showed no remaining aneurysm of the sinus of Valsalva (Fig. 1, E). CASE 2. A 25-year-old man had had septic endo carditis 2 years before admission to the hospital at which time a severe aortic insufficiency was verified in a huge heart of 820 ml. per square meter of body surface area, with a total volume of 1,600 ml. During angiography, the left ventric ular diastolic volume was 740 ml. and the sys tolic volume was 210 ml. Thoracic aortography showed an almost free aortic régurgitation (Fig. 2, A). At operation on Jan. 28, 1964, the non coronary aortic cusp was found to have a septic perforation of 15 mm. in diameter. At the base of the right aortic cusp below the right coronary artery there was a small erosive aneurysm, 5 mm. in diameter (Fig. 2, B). The cusp was excised and a No. 11 ball-valve prosthesis was introduced. The sutures also occluded the small erosive aneu-
Volume 50 Number 1
Aneurysm of sinus of Valsalva
17
July, 1965
Fig. \A. Case 1. Thoracic aortography. Patient in left anterior oblique position. Severe aortic in sufficiency with complete filling of left ventricle (LV). Aneurysm with a diameter of 1 cm. from the noncoronary sinus (arrows).
m φ"*% m m^ß^^^^^^s^^;^ Fig. IB. Diagram of the findings at operation—a large perforation in the right aortic cusp (R), and a small perforation in the left (L), as well as a thumb-sized aneurysm of the noncoronary sinus of Valsalva.
Fig. 1. C and D. Diagram of how the sutures were placed in order to occlude the opening of the aneurysm of the sinus of Valsalva.
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Björk and Björk
Journal of Thoracic and Cardiovascular Surgery
Fig. IE. Aortogram of same patient made 10 months postoperatively. Starr-Edwards prosthesis in the aorta. No aortic insufficiency. The coronary sinus aneurysm is obliterated.
Fig. 2A. Case 2. Thoracic aortography demonstrates aortic insufficiency. On this early film in the series the leakage through a perforation in the noncoronary cusp can be seen (arrows).
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Aneurysm of sinus of Valsalva
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July, 1965
rysm. The patient died in circulatory failure 1 week after the operation because of myocardial infarction. CASE 3. A 40-year-old man with polyarthritis had severe aortic insufficiency with a huge heart of 1,710 ml. total volume, corresponding to 940 ml. per square meter of body surface area. Aortography showed that contrast medium injected into the aorta was found with the same density in the left ventricle which also indicated a severe aortic insufficiency. There was also a small aneu rysm in the right sinus of Valsalva (Fig. 3, A). The diastolic volume of the left ventricle was 740 ml. and the systolic volume 280 ml. In other words there was a very large volume of residual blood in the left ventricle. Left ventricular pres sure was 110/20 mm. Hg when the aortic pres sure was 155/60. When the patient was connected to the heart-lung machine and the aorta was opened, 3 prolapsing cusps were found as well as a small erosion aneurysm, as large as the end of a fingertip, at the base of the right aortic cusp (Fig. 3, B). A No. 11 Starr-Edwards ballvalve prosthesis was inserted and the sutures were placed so as to occlude the aneurysm of the sinus of Valsalva. Immediately after the operation the patient was found to have a diastolic murmur which increased in intensity, although the heart diminished in size from 920 ml. to 580 ml. per square meter. Repeated aortography demonstrated a leakage of contrast medium through a slitformed opening at the side of the valve prosthesis (Fig. 3, C ) . A reoperation was therefore per formed 7 months later at which time two holes were found at the side of the ball-valve prosthesis (10 and 3 mm., respectively). Both holes were
Fig. IB. Diagram demonstrates a small erosive aneurysm of 5 mm. in diameter at the base of the right coronary artery as well as a 15 mm. septic perforation in the noncoronary cusp (NC).
Fig. 3/4. Case 3. Thoracic aortography, lateral view. Free aortic insufficiency with complete filling of left ventricle (LV). Aneurysm of the sinus of Valsalva originates from the right coronary sinus (arrow).
Fig. 3B. Diagram demonstrates an erosion aneu rysm, 10 mm. in size, at the base of the right aortic cusp, as well as three prolapsing cusps.
Journal of
2 0 Björk and Björk
Thoracic and Cardiovascular Surgery
uneventful recovery. The recurrent leakage around the prosthesis could not be directly as cribed to the aneurysm of the sinus of Valsalva as the lesion was found on each side of the site of this aneurysm.
Fig. 3C. Aortogram of the same patient made postoperatively. The Starr-Edwards prosthesis is competent. Leakage through a small opening lateral to the prosthesis (arrow). Aneurysm of the sinus of Valsalva is obliterated. closed by mattress sutures over a strip of Dacron over to the Teflon cuff of the ball-valve prosthesis. The increased flow due to the insufficiency caused a systolic gradient of 60 mm. Hg over the aortic ostium. This gradient was completely abolished after closure of the holes. The patient made an
CASE 4. A 29-year-old man was found to have a continuous heart murmur when he was 10 years of age. He did not come for medical treatment until the age of 29 years when there was a con tinuous murmur and thrill and a large heart of 710 ml. per square meter of body surface area. There was moderate right hypertension and a left-to-right shunt to the right ventricle. Satura tion in the superior vena cava was 74 per cent, in the right atrium 71, right ventricle 95, and the pulmonary artery 88. The systolic pulmonary ar tery pressure was 40 mm. Hg. Thoracic aortography verified an aneurysm of the sinus of Val salva, ruptured into the right ventricle. At the operation in May, 1960, the patient was connected to the heart-lung machine and right ventriculotomy exposed a finger-sized aneurysm in the right ventricle originating from the right sinus of Val salva. The aneurysm had two perforations in the wall. It was excised and closed by direct suture. Immediately adjacent to the aneurysm was a 7 by 3 mm. ventricular septal defect which was also closed by a row of isolated sutures (Fig. 4). The patient made an uneventful recovery and 1 year later no shunt could be found at right heart catheterization. The heart had diminished from 800 to 610 ml. per square meter of body surface area. CASE 5. An 8-year-old boy had been admitted to the hospital because of a congenital aortic in sufficiency. The heart had rapidly increased in
^M\
«pif
Fig. 4. Case 4. Diagram demonstrates aneurysm of the sinus of Valsalva from the right sinus of Valsalva prolapsing into the right ventricle which has two perforations in the wall. Adjacent to the aneurysm was a 7 by 3 mm. ventricular septal defect which was also closed by a row of isolated sutures.
Volume 50 Number 1
Aneurysm
of sinus of Valsalva
2 1
July, 1965
size to 850 ml. per square meter of body sur face area. The patient was operated upon on Dec. 4, 1963. When the patient was connected to the heart-lung machine and the aorta was opened, it was found that there was a large aneurysm of the right sinus of Valsalva with a 10 to 20 mm. perforation in the bottom of the aortic cusp open ing into the left ventricle. The hole was sur rounded by thick fibrotic edges. The noncoronary cusp, however, was prolapsing and also caused aortic insufficiency. As the patient was a child of 8 years of age the hole at the bottom of the right cusp into the left ventricle was closed by a row of direct sutures. The patient withstood the operation well and was much improved. Al though some aortic insufficiency remains, the heart has significantly diminished in size. Within 2 weeks after operation, it had decreased from 850 to 740 ml. per square meter of body surface area.
Discussion In cases of the combination of aortic insufficiency and an erosion aneurysm of the sinus of Valsalva, a septic origin is obvious. Also, in our patient with the aneurysm that ruptured into the left ventricle, it seems obvious that an infection has been the cause of the aneurysm. In the other case of a bulging aneurysm of the sinus of Valsalva into the right ventricle, a septic cause of the aneurysm is probable, although not as obvious. In cases of erosion aneurysm of the sinus of Valsalva in connection with aortic valvular insufficiency, it is most im portant to try to obliterate the aneurysm of the sinus of Valsalva with the sutures fixing the prosthesis in the aortic orifice. If only one edge of the aneurysm will fix the prosthesis, there is a great risk of the su tures cutting through. If, however, the sutures in the root of the aorta are buffered with Teflon pearls and the mattress sutures take bites of the wall on both sides of the aneurysm this will be avoided. The collar of the prosthesis will then reinforce the aortic wall and prevent the sutures from cutting through. In the first case, in which a rather large aneurysm of the sinus of Valsalva bulging into the right atrium was excluded in the way just described by the
sutures fixing the ball-valve prosthesis, no aneurysm could be found at the angio graphie examination at follow-up. In Case 3, a recurrent aortic insufficiency at the side of the Starr valve prosthesis was found. However, the site where the sutures had cut through was not in the base of the right aortic cusp where an aneurysm had been obliterated; it was, instead, at the site of the commissures where too much tension had caused the sutures to cut through. These two observations prove that it is possible to obliterate an erosion aneurysm of the sinus of Valsalva with the same su tures that secure the ball-valve prosthesis in the aortic orifice. In the case of ruptured aneurysm of the sinus of Valsalva, not asso ciated with aortic insufficiency, the aneurysm is excised and closed by direct suture. Summary Diagnostic and therapeutic aspects in 3 cases of erosion aneurysm of the sinus of Valsalva in association with aortic insuffi ciency are discussed, as well as those in 2 cases of ruptured aneurysm of the sinus of Valsalva. REFERENCES 1 Aletras, H., Björk, V. O., Cullhed, I., and Intonti, F.: Ruptured Congenital Aneurysm of the Sinus of Valsalva With Ventricular Septal Defect, Thorax 18: 127, 1963. 2 Björk, V. O.: Aortic Valve Replacement, Thorax 19: 369, 1964. 3 Harken, D. E„ Soroff, H. S., Taylor, W. J., Lefefnine, A. A., Gupta, S. K., and Lunzer, S.: Partial and Complete Prostheses in Aortic In sufficiency, J. THORACIC & CARDIOVAS. SURG. 40:
744, 1960. 4 Kjellberg, S. R., Mannheimer, E., Rudhe, U., and Jonsson, B.: Diagnosis of Congenital Heart Disease, ed. 2, Chicago, 1959, Year Book Pub lishers, Inc. 5 Starr, A., Edwards, M. L., McCord, C. W., and Griswold, H. E.: Aortic Replacement: Clinical Experience With a Semi-Rigid Ball-Valve Pros thesis, Circulation 27: 779, 1963.