Non-anastomotic rupture of the Valsalva graft 6 years after undergoing the Bentall procedure

A 72-year old man with an unruptured aneurysm of the right sinus of Valsalva and aortic insufficiency underwent aortic root replacement using a valved composite graft created with a 28-mm woven Dacron graft (Gelweave Valsalva™ graft, Vascutek Terumo, Renfrewshire, Scotland) and a 25-mm stented bioprosthetic aortic valve (Carpentier-Edwards PERIMOUNT pericardial bioprosthesis, Edwards Lifesciences, Irvine, CA, USA). His postoperative course was uneventful. He had undergone a follow-up CT scan once a year. Although no abnormal signs were detected 5 years after surgery, a CT scan performed in the sixth postoperative year revealed an aortic false aneurysm around the Dacron graft. The false aneurysm enlarged over time and he underwent elective surgery. Two small holes were identified in the 'sinus' portion of the Valsalva graft. The holes were located at the site of the vascular prosthesis corresponding to the level sandwiched between the strut of the bioprosthetic aortic valve and the main pulmonary artery. Therefore, the vascular prosthesis could be exposed to persistent pulsatile contact with the strut resulting from pulsation of the pulmonary artery. This contact/friction might result in fraying of the fabric of the vascular prosthesis, finally leading to non-anastomotic rupture of the Valsalva graft.