DR VIVEK SHARMA

CAREMAX HOSPITAL ,JALANDHAR

 67 yrs male
 HTN
 DCMP
 Severe LV systolic dysfunction
 Ef 35 %
 Atrial fibrillation
 Recurrent TIA
 Drowsiness
 Altered sensorium
 breathlessness
 h/o doe class 2 from few days
 P=130 AF FVR
 Bp 110/60 MMHG
 Chest B/L basal crepts
 CVS –irregular heart sounds
 CNS --intact
 Mild facial +pedal edema noted
 His Trop i was negative and BNP was > 1000
 Case of DCMP, severe LV systolic dysfunction
 CHF
 AF -FVR
 CVA ?
 Patients drowsiness and altered sensorium
improved with overnight BiPAP and diuretic,
Amiodarone and other drug supports

 Patient still needed bipap support

 Echocardiography revealed strange findings
 It ischemic Cardiomyopathy with RWMA in
lad and LCX territory , LVEF was 35%
 A continuous FLOW noted in RA origination
from some chamber situated just besides the
SUPERIOR wall of RA, near IAS attachment to
RA
 It was continous fow-- eccentic jet
ORIGINATING near IAS swirling towards
anterolateral spect of ra
 WHAT COULD BE THE REASON OF THE FLOW ?
 FROM WHERE UNUSUAL CHAMBER APPEARED?
 WHY PATIENT TAKING TIME TI RECOVER ?
 PSEUDOENURYSM FORMATION AT LATERAL
WALL OF RV SOMEHOW LEAKING IN RA FROM
RV ---NO EVIDENCE IN ECHO

 SUPRACARDIAC PAPVC – NO CLINIACVL

EVIDENCE

 COR TRIATRIUM – ANATOMY UNLIKELY

 LEAKING OF SOME CARDIAC VEIN

 AFTER FURTHER ASSESMENT
1. IN PLEX , 4 C VIEW OR SHORT AXIS VIEW IT
WAS HARD TO DETECT THE JET AS WELL AS
THE ANUYRYSM

2. IN 5 CHEMBAR ANEYURM WAS NOTED BUT

RUPTURE WAS NOR SEEN

3. USUALLY SINUS OF VALSALVA ANEUYRYSM

CAN BE EASILY SEEN IN SHORT AXIS VIEW OR 5
CHAMBER VIEW AS WELL RUPTURE CAN BE
DETECTED ON HIGH INDEX OF SUSUSPECION

4. FLOW USUSALLY DETECTED IN RV

 IF WE HAVE SUSPECTED AS CASE OF RUPTURE
OF SINUS OF VALSAVA
 WHERE IS THE ORIGIN OF JET
 TO CLEAR THIS DILEEMMA WE DID CARDAIC
MRI …BUT TO NO AVAIL
 AORTOGRAM DONE IN CATH LAB

 SHOWS THE ANBNORMAL ANEURYSM OF

SINUS OF VALSAVA AS WELL IT JET GOING TO
RA
 RSOV is a rare cardiac anomaly with the
reported incidence of (0.5%-1.5%) in western
and (1.2%-4.94%) in Asian population.

 Most frequently it is congenital in origin due

to either a congenital absence of continuity
between the aortic media and the annulus
fibrosus, or a developmental structural defect
in the aortic annulus itself which can
gradually give way under aortic pressure to
form an aneurysm.
 can rupture into a low pressure cardiac chamber.

 The other causes include trauma, bacterial endocarditis,

syphilis, cystic medial necrosis and atherosclerosis.
 It commonly originates in the right coronary sinus followed
by non-coronary sinus and ruptures into the right ventricle
followed by right atrium

 left coronary cusp does not usually arise from the bulbar
septum as do the right and noncoronary cusps, thus
explaining the rarity of ruptured left sinus of Valsalva
aneurysm.

 In most of the patients diagnosis is generally made in the

third decade and out of them 51-88% are males.
As the reported mean survival of these patients with
untreated RSOV is 3.9 years

and in view of dramatic clinical presentations of sudden

onset biventricular failure, reported low perioperative
mortality and high long term survival after surgery, an early
surgical intervention is indicated as soon as the diagnosis is
made.

The most common coexisting cardiac anomaly with RSOV is

VSD with an incidence ranging from 09- 78%.
 ADIVSED AVR
 THANK YOU