Case Report
Unruptured Sinus of Valsalva Aneurysm
 

Rare Presentation of Unruptured Sinus of Valsalva Aneurysm
Involving All Three Sinuses.
Khandenahally Shankarappa Ravindranath, Seetharam Bhat, Kasam Setty
Subramanyam, Chandrashekaran Dhanalakshmi

Sri Jayadeva Institute of Cardiology, Bangalore, India

Abstract

A patient aged 35yrs presented with the complaint of exertional breathlessness, chest pain and palpitations of 6 months duration. She was not a known diabetic or hypertensive. CVS and RS systems examination did not reveal any positive findings. ECG showed T wave inversion in lead I, avL,V5 and V6. Chest X ray showed no Cardiomegaly. 2D echocardiography showed situs solitus, unruptured aneurysm of sinus of valsalva involving the left sinus filled with SEC and clot, Aneurysm measuring 6.2X3.5 cm, Mild MR, normal LV function, Aortic root angiogram done showed hugely dilated left aortic sinus with stasis, moderately dilated non-coronary sinus and mildly dilated right coronary sinus. Patient was taken up for surgery. All the 3 sinuses were dilated and filled with organized clot. Organized thrombus was removed from all the 3 sinuses and reconstruction of all the sinuses was done with pericardial patch avoiding injury to respective coronary ostia. Post op period was uneventful. Follow up echocardiogram showed near normal dimensions of all the 3 sinuses of valsalva, normal biventricular function and no regional wall motion abnormalities.

Keywords: Sinus of Valsalva, Ruptured aneurysm

INTRODUCTION

A congenital sinus of valsalva aneurysm (SVA) is usually clinically silent but may vary from a mild, asymptomatic dilatation detected in routine 2D echocardiography to symptomatic presentation related to the compression of the adjacent structures1,2 or intra-cardiac shunting caused by rupture of the SVA into the right side of the heart. Approximately 65-85% of SVA originate from the right sinus, 10-30% from the non-coronary sinus and only<5% from the left sinus3. Unruptured aneurysm of all the three sinuses is very rare.

Case Presentation

We encountered a 35 yrs female patient who presented with exertional dyspnoea and palpitations of 6 months duration. Clinical examination was unremarkable. ECG showed insignificant T wave changes in lead I, aVL, V5 and V6. There was no cardiomegaly on chest x-ray.

2D echocardiogram revealed a large unruptured aneurysm of left sinus of valsalva, possibly congenital in origin measuring 6.2X3.5 cm, with no significant hemodynamic compromise and good biventricular function.

Aortic root angiogram was done which showed hugely dilated left aortic sinus with dye stasis, and also moderate dilatation

of other two sinuses as well.

Patient underwent elective operation. All the 3 sinuses were dilated and filled with organized clot. Organized thrombus was removed from all the 3 sinuses, and reconstruction of all the sinuses was done with pericardial patch avoiding injury to respective coronary ostia.

Post operative period was uneventful. Follow up echocardiogram showed near normal dimensions of all the 3 sinuses of valsalva, normal biventricular function and no regional wall motion abnormalities. HPE of the diseased aortic wall suggested nonspecific chronic inflammation.

Aneurysm of all the three aortic sinuses is rare. We present one such case and to the best of our knowledge this is the first case report with these features in India.

Discussion

The sinuses of Valsalva are three small dilatations in the wall of the aorta immediately above the attachments of each aortic cusp. Sinus of valsalva aneurysm is uncommon and is caused by dilatation, usually of a single aortic sinus. The lesion may be the result of the absence of the normal elastic tissue and media in this region. The congenitally weak area gradually gives way under aortic pressure to form an aneurysm. Majority of these aneurysms originate in the right or non-coronary sinus.The aneurysm tends to be single and dilatation of all the

Correspondence: Dr. K.S.Ravindranath, Professor of Cardiology, Sri Jayadeva Instute of Cardiology, Bannerghatta Road, 9th Block Jayanagar, Bangalore 560069, Karnataka, India, E-mail: nishanth_86@yahoo.com

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three sinuses has been reported very rarely4.

Sinus of valsalva aneurysm remains asymptomatic and undetected unless symptoms occur. In rare instances unruptured sinus protrudes into right ventricular outflow tract (RVOT) and can cause RVOT obstruction. There have also been few reported ones in which an unruptured sinus has presented with dyspnoea on exertion, palpitation and chest pain5.

Approximately 25% of reported cases of SVA are clinically asymptomatic, unruptured SVA detected by routine 2D echocardiography. Rupture of the aneurysmal sac may occur spontaneously6, precipitated by exertion, trauma or cardiac catheterization. 90-95% originate in the right coronary sinus or the non coronary sinus. Only <5% originate in the left coronary sinus7,8.

We encountered a 35 year old female patient who presented with dyspnoea on exertion, chest pain and palpitation of 6 months duration. Clinical examination was unremarkable. ECG showed insignificant T wave changes, chest x-ray showed no cardiomegaly.

Echocardiography showed a large unruptured aneurysm of left sinus of valsalva possibly congenital in origin measuring 6.2X3.5 cm with no significant hemodynamic compromise and good biventricular function. Aortic root angiogram was done which showed hugely dilated left aortic sinus with dye stasis and also moderate dilatation of other two sinuses as well. This stresses the importance of other diagnostic modalities in

the management of aneurysm of sinus of valalva. This patient underwent elective surgery. To the best of our knowledge this is the first case report of aneurysm of sinus of Valsalva involving all the three sinuses.

References

1. Kerber RE, Ridges JD, Driss JP, et al.. Unruptured aneurysm of sinus valsalva producing RVOTO. Am J Med ;53:775.1972

2. OkitaY,Miki.S.,Kusuhara K,UedaY,et al. :A giant aneurysm of the noncoronary sinus of valsalva.Thorac Cardiovasc Surg 35;316,1987.

3. Sakakibara S, Konno W. Congenital aneurysms of sinus of valsalva : a clinical study. Am Heart J 63:708.1962.

4. Mick's R.H. :Congenital aneurysm of all 3 sinuses of Valsalva.BHJ 2.63 1940.

5. Liav CS,Chu IT, Hofu :Unruptured congenital aneurysm of SOV presenting with PS :CCVI 1999:46:210.

6. BurakovskyV I, Podosolkov V P, Sabirow BN, et al. :Ruptured congenital aneurysm of the sinus of valsalva. J Thorac Cardiovasc Surg 95:836,1988.

7. Eliot.R.S,Wollbrink,A and Edwards J E ,:Congenital aneurysm of the left aortic sinus.A rare lesion and a rare cause of coronary insufficiency.Circulation 28:951,1963.

8. Sakakibara,S and Konno S,:Congenital aneurysm of the sinus of valsalva:anatomy and classification. Am H eart Journal 63:405,1962.

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Indian Heart J. 2009; 61:121-122