Rupture of an aneurysm of the noncoronary sinus of Valsalva into the right atrium
Department of Cardiology and Angiology, University Hospital of Freiburg, Hugstetter Strasse 55, 79106 Freiburg, Germany
Received 12 July 2007; accepted after revision 29 July 2007; online publish-ahead-of-print 1 October 2007.
* Corresponding author: Tel: +49 270 3441; fax: +49 270 3200. E-mail address: felix.guenther{at}uniklinik-freiburg.de
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A 32-year-old woman presented to the emergency department after the sudden onset of palpitations, dyspnoea and left-sided tinnitus. Echocardiography revealed a ruptured aneurysm of the noncoronary sinus of Valsalva into the right atrium. Due to deterioration of right heart failure with rapidly progressive decline of systemic blood pressure, the patient underwent immediate surgery with a patch repair of the ruptured aneurysm. A few days later, the patient was discharged home in good condition.
Keywords: Sinus Valsalva; Ruptured aneurysm; Congestive heart failure; Echocardiography
A 32-year-old woman presented to the emergency department after the sudden onset of palpitations, dyspnoea and left-sided tinnitus. Past medical history was significant for an unknown congenital heart defect, which was diagnosed in early childhood but not followed since then. Physical examination was remarkable for sinus tachycardia, trace ankle edema and a continuous systolic–diastolic cardiac murmur. Transthoracic echocardiography in the apical four-chamber view revealed hyperdynamic ventricular function and normal dimensions of both ventricles. A jet in the right atrium was visualized which appeared initially to be due to a high grade tricuspid valve regurgitation. However, the gradient of the jet was approximately equivalent to the systolic arterial blood pressure (Figure 1A). Parasternal windows were not sufficient to evaluate the exact anatomical configuration.
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A transesophageal echocardiography was then performed and revealed a ruptured aneurysm of the noncoronary sinus of Valsalva into the right atrium (Figure 1B and C). Due to further worsening of symptoms associated with right heart failure (cyanosis and partial respiratory insufficiency) with rapidly progressive decline of systemic blood pressure, the patient underwent immediate surgery with a patch repair of the ruptured aneurysm (Figure 1D). No ventricular septal defect (VSD) or other commonly associated cardiac defects were found. Ten days after surgery, the patient was discharged home in good condition with the complete resolution of her symptoms.
Aneurysms of the sinus of Valsalva comprise less than 1% of congenital cardiac defects.1 They are caused by a continuity defect of the aortic medial layer in the wall of the sinus and are usually asymptomatic. Rupture of the aneurysm can present with a variety of symptoms ranging from an asymptomatic murmur to cardiogenic shock. Aneurysms arising from the right coronary sinus are the most common and usually extend and rupture into the right heart chambers. The noncoronary sinus is involved less frequently, and mostly penetrates into the right atrium.1,2
Surgical correction of ruptured sinus aneurysms should be performed promptly by a patch closure of the defect and repair of any associated lesions (e.g. VSD).1–3 Results and long-term prognosis after surgical repair are generally excellent.1,3 There are also reports about successful percutaneous closure of ruptured sinus aneurysms by occluder devices.4 In this particular case, the closure with a surgical patch of a hemodynamically significant ruptured aneurysm of the noncoronary sinus into the right atrium with rapidly worsening heart failure appears to have been a successful strategy for management.
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Supplementary material associated with this article can be found in the online version.
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- Dong C, Wu QY, Tang Y. Ruptured sinus of Valsalva aneurysm: a Beijing experience. Ann Thorac Surg (2002) 74:1621–4.
[Abstract/Free Full Text] - Shah RP, Ding ZP, Ng AS, Quek SS. A ten-year review of ruptured sinus of Valsalva: clinico-pathological and echo-Doppler features. Singapore Med J (2001) 42:473–6.[Medline]
- Takach TJ, Reul GJ, Duncan JM, Cooley DA, Livesay JJ, Ott DA, et al. Sinus of Valsalva aneurysm or fistula: management and outcome. Ann Thorac Surg (1999) 68:1573–7.
[Abstract/Free Full Text] - Abidin N, Clarke B, Khattar RS. Percutaneous closure of ruptured sinus of Valsalva aneurysm using an amplatzer occluder device. Heart (2005) 91:244.
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