A 53-year-old man had recurrent angina after single coronary artery bypass grafting (left internal thoracic artery [LITA] to the left anterior descending coronary artery [LAD]). Subsequent investigations showed an aortic root mass (A) (see computed tomographic scan, Figs 1A and 1B) behind the main pulmonary artery (MPA), arising from the aortic sinus (see Fig 2; transesophageal echocardiographic, long-axis view at mid-esophageal, aortic valve level; LA = left atrium; Asc Ao = ascending aorta; LV/RV = left/right ventricle; LVOT = left ventricle outflow tract). The LITA graft was patent, but the distal run-off was small, serving a hypokinetic region.Fig 2View Large Image Figure ViewerDownload (PPT) Intraoperatively a large true Sinus of Valsalva aneurysm was identified just below the left coronary orifice (Fig 3; LCA = left coronary artery). An uneventful pericardial patch closure of the aneurysm neck was performed. As the native LAD was small and the anterior left ventricular motion was poor, the vessel was not re-grafted. An aortogram was not performed in his pre-CABG angiography, but an unusually large gap between the LAD and circumflex arteries (Cx) was already evident (Fig 4; OM = obtuse marginal; D1 = first diagonal branch). In retrospect, the smooth but long segment stenosis on the proximal LAD and the abnormal distance from circumflex suggested the presence of a space-occupying lesion. Sinus of Valsalva aneurysm is rare and only 1% arise from the left [1Guo D.W. Cheng T.O. Lin M.L. Gu Z.Q. Aneurysm of the sinus of Valsalva: a roentgenologic study of 105 Chinese patients.Am Heart J. 1987; 114: 1169-1177Abstract Full Text PDF PubMed Scopus (55) Google Scholar]. Coronary insufficiency as a result of external compression is uncommon but should be considered in angina with unusual angiographic appearances [2Lijoi A. Parodi E. Passerone G.C. Scarano F. Caruso D. Iannetti M.V. Unruptured aneurysm of the left sinus of Valsalva causing coronary insufficiency: case report and review of the literature.Tex Heart Inst J. 2002; 29: 40-44PubMed Google Scholar].

Preoperative use of angiotensin-converting enzyme inhibitors in cardiac surgery patients is thought to cause extreme vasodilatation in post cardiopulmonary bypass period. Opinions are divided as to whether it is beneficial or not to stop it prior to operation. A national survey in the UK was carried out on this issue. Questionnaires were sent to 167 currently practicing UK cardiac surgeons, out of which 105 (62%) replied back. Their responses were analyzed. Among the surgeons who replied to the questionnaires, the majority (63%) were of the opinion that the use of angiotensin-converting enzyme inhibitors leads to vasodilatation resulting in increased usage of fluids, inotropes and vasoconstrictors. However, there was no agreement on the issue of stopping it prior to surgery. Forty one (39%) felt it was beneficial to stop the angiotensin-converting enzyme inhibitors prior to surgery whereas 40 (38%) of them thought it was harmful to stop it. Twenty one (20%) were of the opinion that it made no difference. 39% of respondents practiced stopping the drug prior to planned operation. This national survey revealed differences in management of patients on angiotensin-converting enzyme inhibitors undergoing cardiac surgery. Recommendations from available literature are equally varied, highlighting the need for multicenter randomized trials to address this clinical problem.