Indian Heart J. 2005 Jan-Feb;57(1):73-5.

Ruptured
Source

left sinus of valsalva aneurysm to right atrium.

Dwivedi SK, Saran RK, Sethi R.

Department of Cardiology, King George's Medical University, Lucknow. skdwivedi_dr@rediffmail.com

Abstract
A 6-year-old child presented with left sinus of Valsalva aneurysm opening in right atrium. Origin of sinus of Valsalva from left aortic sinus and its opening into right atrium is extremely rare. The anomaly was corrected surgically by patch closure at the aortic end. Follow-up echocardiography did not reveal any residual shunt in right atrium

DISCUSSION An Esp Pediatr. 2002 Jan;56(1):57-60. [Ruptured aneurysm of the sinus of Valsalva in a boy with ventricular septal defect]. [Article in Spanish] Gmez Lpez L, Martn Mat M, Gallardo Hernndez F, Navas Heredia C, Gonzlez Armengod C, Centeno Malfaz F. Source Servicio de Pediatra, Hospital Po del Ro Hortega, Valladolid. Abstract Aneurysmal dilatation of the sinus of Valsalva is a rare structural cardiac abnormality in children. It appears to be more common in Asia. It may be clinically silent for many years but these defects frequently coexist with other cardiac malformations, causing, when rupture occurs, unexpected symptoms that are not explained by the original defects. We report a case of ruptured aneurysm of the sinus of Valsalva in a 12-year-old boy diagnosed with ventricular septal defect in the neonatal period with an uneventful course. The boy suddenly developed acute prechordal pain, symptoms of low heart output and systolic-diastolic murmur. The diagnosis of ruptured aneurysm of the sinus of Valsalva was based

on echocardiography. Surgical treatment was required to close the ventricular septal defect and repair the aorta, without valvular replacement. The postoperative course was uneventful. We conclude that is extremely important to have a degree high suspicion of this entity in previously asymptomatic children, with or without cardiac anomalies, who suddenly present this kind of heart failure and abrupt changes in cardiac auscultation. Singapore Med J. 2001 Oct;42(10):473-6. A ten-year review of ruptured sinus of valsalva: clinico-pathological and echoDoppler features. Shah RP, Ding ZP, Ng AS, Quek SS. Source Department of Cardiology, Gleneagles Medical Centre, Penang, Malaysia. dr_rajesh_shah@hotmail.com Abstract Rupture of the sinus of valsalva (RSOV) is an uncommon condition with a variety of manifestations ranging from an asymptomatic murmur to cardiogenic shock. This retrospective 10-year review (1985-1995) of 18 patients from a single institution revealed that 6 (33%) were female and 12 (67%) were male with a mean age of 37.6 +/- 13.4 years and that 72% were Chinese by ethnic descent with the remaining 28% being Malay. Eight patients (44.4%) presented with an asymptomatic murmur, 4 (22.2%) with acute chest pain, 4 (22.2%) with mild heart failure, 2 (11.1%) with severe heart failure, and 2 (11.1%) with cardiogenic shock. Rupture of the right aneurysmal coronary cusp (RCC) made up 15 (83.3%) while those of the non-coronary cusp (NCC) made up the remaining. Most of the RCC ruptures were directed into the right ventricle and all of the NCC ruptures were into the right atrium. Ventricular septal defects (VSDs) were found in 9 (50%) of the patients, (although detected by echocardiography in only one third of those

patients), aortic regurgitation in 6 (33.3%) and aortic valve vegetations in 2 (11.1%). Echocardiography was found to be accurate in diagnosing RSOVs with 100% diagnostic accuracy after 1990 with four misdiagnoses before 1990. Of these four patients, two were misdiagnosed as having VSDs, one as having a coronary arteriovenous fistula and one as having a patent ductus arteriosus. The anatomical structure of the "windsock" was seen in 64% of the patients who were correctly diagnosed. The pattern of colour flow and spectral Doppler was seen in all patients and helped to localise the site of rupture and the direction of flow. In summary, echocardiography is a simple and accurate way of diagnosing and defining RSOVs and is the imaging modality of choice. PMID:

11874151

[PubMed - indexed for MEDLINE] Pediatr Cardiol. 1999 May-Jun;20(3):212-4. Congenital aneurysm of sinus of valsalva ruptured into right ventricle diagnosed by magnetic resonance imaging. Karaaslan T, Gudinchet F, Payot M, Sekarski N. Source Department Switzerland. Abstract Rupture of a congenital aneurysm of the sinus of Valsalva is a rare congenital cardiac malformation. This case report describes a congenital aneurysm of the sinus of Valsalva which ruptured into the right ventricle in a 3-year-old girl. The exact route of the fistula through the cardiac walls and the localization of the rupture into the right ventricle was not completely defined by two-dimensional and of Radiology, University Hospital, CHUV-1011 Lausanne,

color Doppler echocardiography and could be determined only by magnetic resonance imaging (MRI). DISCUSSION

Congenital ruptured sinus of Valsalva aneurysm is a rare lesion. Previously, the diagnosis of a ruptured sinus of Valsalva aneurysm in a living patient was rare, with most of the reports coming from autopsy or surgery.[2] Nowadays, the diagnosis is possible with both TTE and transoesophageal echocardiography (TEE). In the patient presented, TTE provided very detailed information to the surgeon. Aneurysms of the sinus of Valsalva account for only 1% of congenital cardiac anomalies. Of these aneurysms, 70% arise from the right sinus of Valsalva. Most of the remainder arise from the noncoronary sinus, and ,5% from the left coronary sinus. [1]. It is produced by mural deficiencies or outpouchings of an aortic sinus that perforate into a cardiac chamber resulting in an aorto-cardiac fistula. The fistula develops either as a windsock deformity or simple fistulous connection.

Clinical presentation is usually within the third decade of life. There are few case reports in children but presentation can range from infancy to seventh decade. Our case was asymptomatic till six years of age when he started developing gradually increasing breathlessness on physical exertion but suddenly deteriorated at twelve years of age when he developed severe respiratory distress with signs of hyperkinetic circulation. The patient was diagnosed as a case of Rheumatic fever with severe aortic regurgitation and was being treated with injection Benzathine

penicillin and steroids until he was referred to our institute. The patient had features of congestive cardiac failure with continuous murmur with acute aortic regurgitation and wide pulse pressure and was diagnosed by TTE .Gomez etal reported a similar case of ruptured aneurysm of the sinus of Valsalva in a 12-yearold boy diagnosed with ventricular septal defect in the neonatal period with an uneventful course. The boy suddenly developed acute precordial pain, symptoms of low heart output and systolic-diastolic murmur. Dattilo etal reported a chance finding of an aneurysm of the right sinus of Valsalva in an 11-year-old Italian child with a ventricular septal defect and a pericardial effusion. Diwedi etal reported an extremely rare case of a 6-year-old child with left sinus of Valsalva aneurysm opening in right atrium. Karaaslan etal described a congenital aneurysm of the sinus of Valsalva which ruptured into the right ventricle in a 3-year-old girl.An increasing number of cases are being reported in the pediatric population because of an increasing awareness of the possibility of this diagnosis by the pediatricians in hyperkinetic circulation and the availability and the ease of this diagnosis by echocardiography. The lesion is five times more common in Asians [1,2,3,4,5]. Various reports indicate a male preponderance in Asians, and a relatively even gender distribution among Caucasians [12,3,45]. However, Shah etal in a retrospective 10-year review (1985-1995) of 18 patients from a single institution in Malaysia revealed that 6 (33%) were female and 12 (67%) were male with a mean age of 37.6 +/13.4 years

Upon presentation, approximately 80% to 85% of patients are symptomatic with dyspnea, pain, palpitations, or fatigue. About 3 of 4 will have gradual onset, while the other 1 of 4 will have acute onset of their symptoms.[1,2,3,4,5]

The right coronary sinus is most commonly affected as in our case, followed by the noncoronary sinus. Rupture of the aneurysm most commonly occurs into the right ventricle followed by the right atrium but it may also rupture into the left ventricle[6], the interventricular septum[7], and the pericardial space[8]. Associated lesions are common in patients with congenital, ruptured sinus of Valsalva aneurysm [1]. Aortic regurgitation occurs in 30% to 75% of patients, and ventricular septal defects, either subarterial or perimembranous, occur with a comparable incidence of 30% to 50%. AI is usually due to cusp prolapse of the affected sinus.[1]In the present case the gradual onset of symptoms at six years of age may be due to slow but progressive development of aortic regurgitation on account of increasing size of aneurysm of right sinus of Valsalva which eventually ruptured at twelve years of age. Although the first reported case of RSOV diagnosed by echocardiography was in 1974[9], the gold standard for diagnosis of this lesion has traditionally been cardiac catheterisation and aortography. With the advent of newer generation ultrasound machines, transthoracic echocardiography and now transoesophageal

echocardiography[10] have taken centre-stage for diagnostic confirmation. . A detailed echocardiographic study (two-dimensional, Doppler, and color flow imaging) is accurate in the diagnosis of ASOV, in the identification of its site of origin and rupture, and in the evaluation of the associated defects; in the vast majority of cases, it can totally supplant the need for angiography.(AIIMS) Workers have also looked at magnetic resonance imaging (MRI)[11] as a diagnostic tool. Although the results are encouraging, the lower cost, equal accuracy, convenience and safety of an echocardiogram, especially in critically ill patients, far outweigh the benefits of MRI.

Surgery should be done as soon as rupture of sinus of valsalva aneurysm is diagnosed because without surgery most cases will die of intractable congestive heart failure. Mean survival without surgery is not more then 1-2 years with optimal medical treatment. CONCLUSION A clinician should always ponder on the unusual etiology of a common aortic valvular lesion like acute aortic regurgitation; in this case report, the etiology was a rupture of the right sinus of Valsalva aneurysm into the right ventricle.

References

1. Kirklin JW, Barratt-Boyes BG. Congenital aneurysm of the sinus of Valsalva. In: Kirklin JW, Barratt-Boyes BG, eds. Cardiac surgery, 2nd ed. ChurchillLivingstone, 1993:825 40.

2. Chu SH, Hung CR, How SS, et al. Ruptured aneurysms of the sinus of Valsalva in Oriental patients. J Thorac Cardiovasc Surg 1990;99:28898.

3. Au WK, Chiu SW, Mok CK, et al. Repair of ruptured sinus of Valsalva aneurysm: Determinants of longterm survival. Ann Thorac Surg 1998;66:160410.

4. Anthony A, David TE, et al. Ruptured Sinus of Valsalva Aneurysm: Early Recurrence and Fate of the Aortic Valve. Ann Thorac Surg 2000;70:1466 71

5. Shah RP, Ding ZP, et al. A Ten-Year Review of Ruptured Sinus of Valsalva: Clinico-Pathological and Echo-Doppler Features. Singapore Med J 2001 Vol 42(10) : 473-476

6. Kucukoglu S, Ural E, Mutlu H, Ural D, Sonmez B, Uner S. Ruptured aneurysm of the sinus of valsalva into the left ventricle: report and review of the literature. J Am Soc Echocardiogr 1997; 10(8):862-5.

7. Abad C. Congenital aneurysm of the sinus of valsalva dissecting into the interventricular septum. Cardiovasc Surg 1995; 3(5):563-4.

8. Brabram KR, Roberts WC. Fatal intrapericardial rupture of sinus of valsalva aneurysm. Am Heart J 1990; 120(6 Pt 1):1455-6.

9. Cooperberg P, Mercier EN, Mulder D, Winsberg GF. Rupture of a sinus of valsalva aneurysm. Report of a case diagnosed pre-operatively by

echocardiography. Radiology 1974; 113:171-2.

10. Wang KY, St John Sutton M, Ho HY, Ting CT. Congenital sinus of valsalva aneurysm: a multiplane transoesophageal experience. J Am Soc Echocardiogr 1997; 10(9):956-63.

11. Kulan K, Kulan C, Tuncer C, Komsuoglu, B, Zengin M. Echocardiography and magnetic resonance imaging of sinus of valsalva aneurysm with rupture into the ventric Echocardiographic diagnosis of aneurysm of the sinus of Valsalva.

Dev V, Goswami KC, Shrivastava S, Bahl VK, Saxena A. Source Department of Cardiology, All India Institute of Medical Sciences, Ansari Nagar, New Delhi. Abstract Echocardiographic and Doppler data of 62 patients with ASOV are presented. Catheterization and angiography were performed in 38 cases and surgery in 25 of the 38. The origin of these aneurysms was the RCS in 56 cases, NCS in 5, and LCS in 1 case. Seven had unruptured aneurysms, 6 rising from RCS dissected into the ventricular septum, producing heart block in 4, AR in 5, mitral regurgitation in 1; 1 aneurysm rising from the LCS was asymptomatic. In other cases (n = 55) the aneurysm had ruptured into one of the cardiac chambers. Thirty-two of the 50 RCS aneurysmsruptured into the RVOT, 13 into the RV cavity, 2 into the RA, and 3 into the LV. Of the 5 NCS aneurysms, (3 ruptured into the RA, 1 into the RV, and 1 into both the RA and RV. Associated VSD was identified in 16 (25.8%) of 62 cases. All of these patients had RCS aneurysms that ruptured into the RVOT. Echocardiography missed VSD in three cases that at surgery were found to have VSD. AR was found in 34 of 62 cases. Echocardiography picked up discrete subaortic stenosis in two cases but missed subvalvar PS in 2 of the 3 cases. A detailed echocardiographic study (two-dimensional, Doppler, and color flow imaging) is accurate in the diagnosis of ASOV, in the identification of its site of origin and rupture, and in the evaluation of the associated defects; in the vast majority of cases, it can totally supplant the need for angiography.

J Cardiovasc Dis Res. 2011 Jan-Mar; 2(1): 7779. doi: 10.4103/0975-3583.78603

PMCID: PMC3120279

Copyright : Journal of Cardiovascular Disease Research Extremely rare case of a rupture of the left sinus of Valsalva aneurysm into the main pulmonary artery Virendra C. Patil, Harsha V. Patil, Sanjay Kshirsagar, and Bhupal Pujari Department of Medicine, Krishna Institute of Medical Sciences University, Karad, Satara 415 110, Maharashtra, India Address for correspondence: Dr. Virendra C. Patil, Department of Medicine, Krishna Institute of Medical Sciences University, Dhebewadi Road, Karad, Satara 415 110, Maharashtra, India. E-mail:virendracpkimsu@rediffmail.com This is an open-access article distributed under the terms of the Creative Commons Attribution-Noncommercial-Share Alike 3.0 Unported, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Abstract We describe a case of ruptured aneurysm of the left coronary sinus of Valsalva diagnosed by transthoracic two-dimensional echocardiography. A very few cases with ruptured left sinus of Valsalva have been reported. We are reporting a rupture of the left sinus of Valsalva into the main pulmonary artery in a 40-year-old male diagnosed by transthoracic echocardiography.

Keywords: Rupture into the main pulmonary artery, sinus of Valsalva, transthoracic echocardiography INTRODUCTION Sinus of Valsalva aneurysm is a rare congenital defect and the diagnosis is usually made after it ruptures. The anomaly most often involves the right coronary sinus and less frequently the noncoronary sinus. Since the aortic valve occupies a central position in the base of the heart, a rupture of a sinus of Valsalva aneurysm can occur in any of the four heart chambers. The rupture of the left sinus of Valsalva into the pulmonary artery is extremely rare.[1,2] CASE REPORT A 40-year-old patient presented with acute onset dyspnea, ascites, and peripheral edema. Physical examination revealed a continuous murmur (Grade 4/6) across the precordium. Blood pressure was 160/60 mmHg with bilateral basal rales. Jugular venous pressure was raised.

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INVESTIGATIONS Hemoglobin was 12 gm%. The total count was 8700 with normal differentiation. Renal and liver functions were normal. A chest X-ray showed an enlarged cardiac shadow and pulmonary congestion. The electrocardiogram revealed right ventricular hypertrophy with a prolonged PR interval (first AV block). Transthoracic two-dimensional echocardiography (TTE) showed a normal left ventricular systolic function. The overall left ventricular ejection fraction was 70%. The left ventricular wall thickness and function was normal. There was severe

aortic regurgitation. All cardiac chambers were dilated with moderate pulmonary, mitral, and tricuspid regurgitation with severe pulmonary hypertension (pulmonary artery pressure: 42.9 mmHg). At the aortic root level, there was an aortopulmonary communication indicating a rupture of the left sinus of Valsalva. The pulmonary artery was dilated. The color Doppler images showed the blood shunting from the aorta to the pulmonary artery. The parasternal short-axis view with the color Doppler technique showed the shunting blood flow from the left sinus of Valsalva through the "wind sock" into the main pulmonary artery [Figures [Figures11 and and22]. Figure 1 Transthoracic two-dimensional echocardiography,

shows the rupture of the left sinus of Valsalva, into the main pulmonary artery, severe aortic regurgitation, moderate mitral regurgitation, moderate tricuspid regurgitation, moderate pulmonary regurgitation (more ...) Figure 2 Transthoracic two-dimensional echocardiogram

showing the rupture of the left coronary sinus of Valsalva into the main pulmonary artery, and severe aortic regurgitation The patient was treated for congestive cardiac failure and referred to a cardiologist and cardiothoracic surgeon for further evaluation and repair. Unfortunately, in the cardiac center the, patient succumbed to death after an episode of ventricular tachycardia and congestive cardiac failure.

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DISCUSSION Previously, the diagnosis of a ruptured sinus of Valsalva aneurysm in a living patient was rare, with most of the reports coming from autopsy or surgery.[2] Nowadays, the diagnosis is possible with both TTE and transoesophageal echocardiography (TEE). In the patient presented, TTE provided very detailed information to the surgeon. We obviously would have performed a TEE had we not reached a precise anatomical description with TTE.[2,3] Aneurysms of the sinus of Valsalva account for less than 1% of congenital cardiac anomalies.[4] A total of 9095% of these congenital aneurysms originate in the right or noncoronary sinus and project into the right ventricle or into the right atrium. Almost all aneurysms arising in the noncoronary sinus rupture into the right atrium and those arising in the right coronary sinus generally communicate with the right ventricle and occasionally with the right atrium.[5,6] In the present case report, a patient showing features of congestive cardiac failure with continuous murmur with acute aortic regurgitation and wide pulse pressure was diagnosed by TTE. Fazio et al.[2] reported a similar and rare case of a rupture of the left sinus of Valsalva aneurysm into the pulmonary artery. Complications of the sinus of Valsalva aneurysms include aortic regurgitation, coronary artery flow compromise, arrhythmias, and rupture. Most commonly, the rupture occurs from the right coronary sinus into the right ventricle or into the right atrium. However, the rupture may also occur into the pericardium, the pleural space, or the left heart chambers.[6] CONCLUSION

A clinician should always remember the unusual etiology of a common aortic valvular lesion like acute aortic regurgitation; in this case report, the etiology is a rupture of the left sinus of Valsalva aneurysm into the pulmonary artery. In the present case, anatomical imaging was achieved enough by TTE to diagnose the rupture of the left sinus of Valsalva aneurysm into the pulmonary artery. Footnotes Source of Support: Nil Conflict of Interest: None declared.

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REFERENCES 1. Kar AK, Bhattacharya S, Ray D, Mondal M, Ghosh S, Mazumdar A. Rupture of the sinus of Valsalva into the pulmonary artery. Indian Heart J. 2002;54:415 7. [PubMed] 2. Fazio G, Zito R, Dioco DD, Mussagy C, Loredana S, Damasceno A, et al. Rupture of a left sinus of Valsalva aneurysm into the pulmonary artery. Eur J Echocardiogr. 2006;7:2302. [ le. J Cardiovasc Surg (Torino) 1996; 37(6):639-41. Cardiol Young. 2003 Apr;13(2):168-72. Echocardiographic presentations of endocarditis, and risk factors for rupture of asinus of Valsalva in childhood. McMahon CJ, Ayres N, Pignatelli RH, Franklin W, Vargo TA, Bricker JT, El-Said HG.

Source Lille Frank Abercrombie Section of Pediatric Cardiology, Texas Children's Hospital, Baylor College of Medicine, Houston, Texas 77030, USA.

cmcmahon@bcm.tmc.edu Abstract BACKGROUND: In recent years, the diagnosis of infective endocarditis has been enhanced by the use of echocardiography. We sought, therefore, to review its effect on the management of endocarditis in children. METHODS: We reviewed all the patients presenting to our institution for evaluation for infective endocarditis from May 1994 to January 2002. The patients were stratified according to whether or not they had congenitally malformed hearts. RESULTS: Of the 90 referred patients identified, 46 (51%) had positive ultrasonic findings. Of these, we excluded 26 patients because of the presence of indwelling lines. The remaining 20 patients with features of endocarditis had a median age of 6.5 years, and a range from 0.14 to 8.5 years. There were 4 patients with normal hearts, and 16 with congenital cardiac malformations. We identified rupture of a sinus of Valsalva in four patients, with rupture into the left ventricle in two, and into the right ventricle and right atrium in one each. The mitral valve was involved in six patients, the aortic valve in another six, including all four with rupture of the sinus of Valsalva, both mitral and aortic valves in three, the pulmonary trunk in three

patients, and the tricuspid valve and a Blalock-Taussig shunt in one patient each. Organisms isolated included Streptococcus mitis in 4 patients, Streptococcus pneumoniae in 2 patients, Streptococcus sanguis in 1, Staphylococcus aureus in 3, Staphylococcus epidermidis in 1, and Enteroccocus in 2. Cultures proved negative in 7 patients. Surgical intervention was needed in 12 patients, and one died (5%). Only the left-sided chambers were involved in those with normal hearts. Both patients infected with Streptococcus pneumoniae had rupture of a sinus of Valsalva. CONCLUSION: Involvement of the left-sided chambers is more likely in structurally normal hearts, and in cases with rupture of a sinus of Valsalva, in which case infection with Streptococcus pneumonia should be suspected.

International Journal of Cardiology Volume 151, Issue 3 , Pages e77-e79, 15 September 2011

The chance finding of an aneurysm of the right sinus of Valsalva in an 11-year-old child with a ventricular septal defect and a pericardial effusion

Giuseppe Dattilo , Domenico Tulino , Viviana Tulino , Annalisa Lamari , Filippo Marte ,

Salvatore Patan Received 21 February 2009; received in revised form 4 March 2009; accepted 5 March 2009. published online 06 April 2009.

Abstract
Ventricular septal defects can occur as part of other congenital cardiac malformations or as an isolated finding. Aneurysms of the sinus of Valsalva are rare, most commonly involving the right or noncoronary sinuses. They can be congenital or acquired through infection, trauma, or degenerative diseases. They frequently co-exist with ventricular septal defects, aortic valve dysfunction, or other cardiac abnormalities. More commonly, sinus of Valsalva aneurysms are diagnosed after the clinical sequelae of rupture. Several etiologic factors may lead to the development of pathologic pericardial effusion and the detection of pericardial effusion was one of the first applications of echocardiography to gain widespread acceptance. We present a case of a chance finding of an aneurysm of the right sinus of Valsalva in an 11-year-old Italian child with a ventricular septal defect and a pericardial effusion.

Abstract Full Text PDF Images References

Echocardiography diagnosis of ruptured congenital right coronary sinus of Valsalva aneurysm into right ventricle 1. Alessandro Iadanza*, 2. Massimo Fineschi, 3. Alessia Del Pasqua and 4. Carlo Pierli +Author Affiliations 1. Department of Cardiovascular Diseases, Azienda Ospedaliera Universitaria Senese, Policlinico Le Scotte, Viale Bracci 1, 53100 Siena, Italy 1. *Corresponding author. Tel.: +39 577 585707. alex.iadanza@tin.it

Received February 13, 2005. Revision requested June 28, 2005. Accepted July 7, 2005.

Next Section Abstract We describe a case of ruptured aneurysm of the right coronary sinus of Valsalva (ASV) diagnosed by transthoracic two-dimensional echocardiography which allowed to quickly establish a correct diagnosis in a patient with a recent onset of continuous murmur and acute right congestive heart failure. Key words

Transthoracic echocardiography

Congenital Coronary sinus of Valsalva aneurysm

Previous SectionNext Section Case report A 45-year-old woman presented with a history of acute dyspnoea, right congestive heart failure and tachycardia. Examination revealed a wide pulse pressure and a continuous murmur across the precordium. Transthoracic two-dimensional echocardiography (TTE) demonstrated an aorta-toright ventricle fistula through a ruptured right coronary sinus of Valsalva. The echocardiogram revealed enlargement of the right chambers and right coronary sinus of Valsalva. Both contrast and color-Doppler techniques showed shunting from the sinus of Valsalva with the typical wind sock appearance into the right

ventricle17 and, passing through the tricuspidal leaflets, into the right atrium (Fig. 1A,B).

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Figure 1 Transthoracic two-dimensional echocardiography. (A) Short axis view shows normal coronary sinus and a mobile wind sock aneurysm protruding into right ventricle; (B) short axis view with color-Doppler technique shows the shunting blood flow from the sinus of Valsalva through the wind sock into the right ventricle; (C) short axis view after surgical repair with Dacron patch; (D) short axis view with color-Doppler technique shows the absence of shunt after surgical repair. Ao, aorta; RA, right atrium; LA, left atrium; RV, right ventricle; TV, tricuspid valve. Aortography showed a non-dilated aortic root and the direction of the shunt from the right coronary sinus towards the right ventricle without any sign of aortic regurgitation. Coronary arteries and the aortic valve were normal.

The suspicion of infective endocarditis was excluded on the basis of patient's history and laboratory analysis. The configuration of the aneurysm was consistent with the contrast medium-filled sinus demonstrated by aortography, with a normal coronary sinus and a mobile wind sock aneurysm protruding into the right ventricle (Fig. 2).

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Figure 2 Right anterior oblique aortogram (Ao) shows sinus of Valsalva aneurysm projecting into the right ventricle across the tricuspid valve. The aneurysm appears as a finger-like or nipple-like projection with a perforation at its tip (black arrow). ao, aorta; ra, right atrium; rv, right ventricle. The surgical approach was from the aortic root. The aortic ostium of the Valsalva aneurysm was successfully repaired with a Dacron patch. A second surgical approach, through right atriotomy, allowed evaluation of the right side of the

aneurysm and excluded the presence of tricuspid valve apparatus lesions. After closure of the aneurysm, two-dimensional echocardiography no longer showed an abnormal configuration (Fig. 1C,D). At 6-month, the patient remained well and asymptomatic and there was no residual tricuspid regurgitation. Previous SectionNext Section Discussion Before the introduction of echocardiography the diagnosis of a ruptured sinus of Valsalva aneurysm in the living patient was rare, with most of the reports coming from autopsy or surgery.1 Nowadays, the diagnosis is possible with both TTE and transoesophageal echocardiography (TEE). In the patient presented, TTE provided very detailed information to the surgeon. We obviously would have performed a TEE had we not reached a precise anatomical description with TTE.8 Angiography in this case was not necessary for the diagnosis but only for excluding coronary stenosis. Aneurysms of the sinus of Valsalva account for less than 1% of congenital cardiac anomalies.4 Ninety to 95% of these congenital aneurysms originates in the right or noncoronary sinus and project into the right ventricle or into the right atrium. Aneurysm arising in the non-coronary sinus almost all rupture into the right atrium, and those arising in the right coronary sinus generally communicate with the right ventricle and occasionally with the right atrium. Complications of sinus of Valsalva aneurysms include aortic regurgitation, coronary artery flow compromise, arrhythmias, and rupture.6

Most commonly, rupture occurs from the right coronary sinus into the right ventricle or into right atrium. However, rupture may also occur into the pericardium, the pleural space, or the left heart chambers.9

Copyright 2005, The European Society of Cardiology

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References 1. 1. Dev V., 2. Goswami K.C., 3. Shrivastava S., 4. Bahl V.K., 5. Saxena A. Echocardiographic diagnosis of aneurysm of the sinus of Valsalva. Am Heart J 1993;126:930-936. CrossRefMedlineWeb of Science 2. 1. Ahmad R.A.S., 2. Sturman S., 3. Watson R.D.S.

Unruptured aneurysm of the sinus of Valsalva with isolated heart block: echocardiographic J 1989;61:375-377. Abstract/FREE Full Text 3. 1. Lewis B.S., 2. Agathangelou N.E. Echocardiographic diagnosis of unruptured sinus of Valsalva aneurysm. Am Heart J 1984;107:1025-1027. CrossRefMedlineWeb of Science 4. 1. Mok C.K., 2. Cheung K.I., 3. Wang R.Y.C. Unruptured right coronary sinus to left ventricle aneurysm diagnosed by cross sectional echocardiography. Br Heart J1985;53:226-229. Abstract/FREE Full Text 5. 1. Rothbart R.M., 2. Chahine R.A. diagnosis and successful surgical repair. Br Heart

Left sinus of Valsalva aneurysm with rupture into the left ventricular outflow tract: diagnosis by color-encoded Doppler imaging. Am Heart J 1990;120:224-227. CrossRefMedlineWeb of Science 6. 1. Rigo T., 2. Zeppellini R., 3. Cucchini F. Rupture of an aneurysm of the noncoronary sinus of Valsalva into the right atrium: the wind sock echocardiographic appearance. Ital Heart J 2001;2(3):237238. Medline 7. 1. Ozeke O., 2. Tufekcioglu O., 3. Geyik B., 4. Yildiz A., 5. Yetim M. Asymptomatic ruptured sinus of Valsalva aneurysm into the right ventricle. Eur J Echocardiogr 2005;6:64. Medline

8. 1. Gurgun C., 2. Ozerkan F., 3. Akin M. Ruptured aneurysm of sinus of Valsalva with ventricular septal defect: the role of transesophageal echocardiography in diagnosis.Int J Cardiol 2000;74:95-96. CrossRefMedlineWeb of Science 9. 1. Henze A., 2. Huttunen H., 3. Bjork V.O. Ruptured sinus of Valsalva aneurysms. Scand J Thorac Cardiovasc

Surg 1983;17:249-253. MedlineWeb of Science Previous | Next Article Table of Contents This Article 1. Eur J Echocardiogr (2006) 7 (5):387-389.doi: 10.1016/j.euje.2005.07.013 1. Abstract 2. Full Text (HTML) 3. Full Text (PDF)

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