Sinus of Valsalva aneurysms

An observational study of symmetrical VSD occluder for transcatheter closure of ruptured sinus of Valsalva aneurysm

This study evaluated the immediate and 1-year postoperative outcomes of 14 patients with ruptured Valsalva aneurysmal sinus (RSVA) using symmetric ventricular septal defect (VSD) occluder for transcatheter closure (TCC). The sites of rupture were from the non-coronary sinus to the right atrium (RA) in 10 cases (71.4%), the right coronary sinus (RCS) to the RA in 3 cases (21.4%) and the RCS to the right ventricle in 1 case (7.2%). The defects (5-11 mm) were closed with a symmetrical VSD device. During the follow-up (12 months), the enlarged heart of the patients had significantly shrunk and the NYHA improved after closure. In 1 case, a moderate residual shunt was present and the patient suffered from hemolysis at 2 h after the operation, and 1 patient was transferred to surgery for aortic regurgitation 1 year after the initial treatment of RSVA. In conclusion, the TCC of RSVA with the China made symmetrical VSD occluder is safe and effective.

Ruptured Sinus of Valsalva Aneurysm in a Patient with a Ventricular Septal Defect Who Dropped Out of Lifelong Medical Follow-up

Ruptured sinus of Valsalva aneurysm (RSOVA) is a rare cardiac condition associated with high morbidity and mortality rates. We herein report a 35-year-old man with a history of ventricular septal defect (VSD). He had a history of interrupted hospital visits and presented to the emergency department with dyspnea, palpitations, and dizziness for a few days. Auscultation detected a continuous murmur. Transthoracic echocardiography followed by transesophageal echocardiography demonstrated RSOVA in the right ventricle with an aorto-right ventricular fistula. The fistula was resected, and the aneurysm was surgically repaired. The patient made a good recovery.

Percutaneous Closure of a Ruptured Sinus of Valsalva Aneurysm under Transesophageal Echocardiography Guidance

•SOVA is a rare cardiac anomaly. •Ruptured SOVA carries a high mortality rate. •SOVA often coexists with other congenital lesions, most commonly VSD and bicuspid AV. •Ruptured SOVA needs repair; percutaneous repair is a safe alternative to surgery. •Echo plays a vital role in both diagnosing SOVA and guiding percutaneous closure.

Congestive Heart Failure in an Adolescent With a Ruptured Sinus of Valsalva Aneurysm

Sinus of Valsalva aneurysm (SVA) is an abnormal dilatation of the aortic root located between the aortic valve annulus and the sinotubular junction and is rare in the pediatric population. This case report describes a unique case of a 16-year-old adolescent patient admitted with progressive heart failure symptoms and diagnosed with a ruptured noncoronary SVA. He underwent surgical repair of the SVA with autologous pericardial patches and had an uncomplicated postoperative course. A genetic workup revealed an underlying 22q11.2 deletion that is infrequently associated with SVA.

Complete heart block caused by sinus of valsalva pseudoaneurysm-A rare case

Acquired pseudoaneurysms of the aortic root involving the sinus of Valsalva (SOV) are rare and serious complications arising from trauma, infection, or following cardiac surgery or intervention. Complete heart block (CHB) is an atypical presentation of SOV pseudoaneurysm due to either direct compression effects or involvement of the main conducting system by blood and inflammatory cell infiltration. Herein, we describe a rare case of a patient who presented with CHB caused by an SOV pseudoaneurysm following polytrauma and was treated with surgical closure of pseudoaneurysm followed by implantation of a permanent pacemaker to treat the persistent CHB.

Intravenous thrombolysis in a patient with acute ischemic stroke associated with a ruptured sinus Valsalva aneurysm: The first case report

Sinus Valsalva aneurysms (SVA) are rare asymptomatic cardiac anomalies, which can rupture and cause heart failure, myocardial infarction and also, they can be a potential source for embolic strokes. We report the first case of a patient with acute ischemic stroke associated with a ruptured SVA, who was treated with intravenous thrombolysis (tPA) without further complications.

Aortic root pseudoaneurysm after blunt trauma to chest - an interesting case

Acquired pseudoaneurysms of the aortic root involving the sinus of Valsalva are rare and serious complications arising from trauma, infection, or following cardiac surgery or intervention. We describe the surgical treatment of a patient who had acquired sinus of Valsalva pseudoaneurysm following blunt trauma to chest; wherein pericardial patch closure of the orifice of the pseudoaneurysm without aortic valve replacement or coronary artery bypass grafting. The management of these sinus of Valsalva pseudoaneurysms depends on the underlying mechanism causing symptoms such as compression or thrombosis of coronary artery; or the defective anatomy involving sinus of Valsalva, aortic valve or the coronary artery.

Extrinsic compression of coronary and pulmonary vasculature

Coronary artery disease from atherosclerosis induced stenosis remains the leading cause of acute coronary syndrome (ACS) and death worldwide, however extrinsic compression of coronary arteries from adjacent anatomical and pathological structures is an infrequent but important diagnosis to be aware of, especially given the nonspecific symptoms of chest pain that mimic angina in patients with pulmonary hypertension (PHT) and congenital heart disease. Non-invasive CT angiography is an invaluable diagnostic tool for detection of coronary artery compression, pulmonary artery dilatation and pulmonary vascular compression. Although established guidelines are not available for management of left main coronary artery (LMCA) compression syndrome, percutaneous coronary intervention and stent implantation remain a feasible option for the treatment, specifically for patients with a high surgical risk. Treatment of pulmonary vein or artery compression is more varied and determined by etiology. This review article is focused on detailed discussion of extrinsic compression of coronary arteries, mainly the LMCA and brief discussion on pulmonary vasculature compression by surrounding anatomical and pathological entities, with focus on pathophysiology, clinical features, complications and role of imaging in its diagnosis and management.

Sinus of Valsalva Aneurysms: A Review with Perioperative Considerations

The sinuses of Valsalva are outpouchings in the aortic root just distal to the aortic valve that serve several physiologic functions. Aneurysm of this segment of the aorta is quite rare and infrequently encountered in clinical practice. Due to the rarity of sinus of Valsalva aneurysms, there is a lack of controlled trials and most of the literature consists of case reports and series. Here, the authors review the currently available literature to discuss the anatomy and normal function of the aortic root, as well as disease pathology and diagnostic imaging considerations. Using reported cases, the authors also will discuss considerations for cardiac anesthesiologists in the perioperative period.

Rupture of sinus of Valsalva aneurysm: case report and review of contemporary literature

Sinus of Valsalva aneurysm rupture is a rare condition with a great potential for morbidity and mortality if not promptly diagnosed and managed. We present an unusual non-infected sinus of Valsalva aneurysm rupture in a 47-year-old female. This case report, a likely presentation of a late congenital heart defect, highlights the need for a high index of suspicion in a patient with atypical history of congestive cardiac failure.

Comparison of clinical results between percutaneous closure and surgical repair of ruptured sinus of Valsalva aneurysm

OBJECTIVES

This study was conducted to investigate whether percutaneous closure of ruptured sinus of Valsalva aneurysm (SVA) is as safe and effective as surgery repair.

BACKGROUND

Percutaneous closure of ruptured SVA has been becoming an alternative to the traditional surgical repair recently. The reports regarding direct comparison of these two treatment options are scarce.

METHODS

The medical records from the institutional database were retrospectively analyzed. A total of 134 patients were reviewed, including 26 patients undergoing percutaneous closure and 108 patients being treated surgically. To reduce the potential bias, 32 patients from Surgical Repair group were selected by propensity score matching.

RESULTS

All the ruptured SVAs were successfully closed in each group. No severe procedure-related complications were found in the perioperative period. After matching, there were no significant differences in the baseline clinical characteristics. The median postoperative hospital stays of Matched group were significantly longer than that of Percutaneous Closure group (7 days vs. 1 day, p < .001). Aortic regurgitation, residual shunt and recurrence of SVAs were common complications in both Percutaneous Closure group and Surgical Repair group.

CONCLUSIONS

The appropriately selected patients with ruptured SVA could be treated by percutaneous closure with an acceptable risk of short-term complications. Though surgical repair remains the main treatment option for ruptured SVAs, percutaneous closure could be considered in patients with a small-size rupture and no associated cardiac abnormalities.

Right sinus of Valsalva aneurysm

Aneurysms in the sinuses of Valsalva (SVA) are the least frequent and occur due to a weakness in the aortic wall that forms part of the sinus. This causes dilatation and the formation of a blind pocket in one of the aortic sinuses (usually he right sinus and less frequently the posterior one). It may be congenital or acquired: in a congenital SVA, the condition is frequently associated with Marfan's syndrome or other connective tissue disorders; instead, acquired forms of sinus of Valsalva aneurysm are associated with infections (syphilis, bacterial endocarditis, and tuberculosis), atherosclerosis and medial cystic necrosis, traumatic and degenerative diseases, abuse of drugs or alcoholism. Despite SVA is a well-known anomaly, autopsy images or reviews of the condition are very uncommon. Indeed we report here a fatal case of SVA in a 58-year-old homeless man found dead on the street. The autopsy, performed to determine the cause of death, releaved a massive aneurysm (in excess of 4 cm) involving the right coronary sinus of the aorta. In this case, the aneurysm may be an accidental finding: in effect we found no tromboses inside the aneurysm and the ostium was not obstructed, therefore the cause of death could be attribuited to fatal arrhythmia.

Cardiac Outpouchings: A Multimodality Imaging Review

Cardiac outpouchings pose a diagnostic challenge when encountered in practice, as the signs, symptoms, and initial investigations, such as radiographs and electrocardiogram, are nonspecific. They may remain asymptomatic and be incidentally detected. However, a few may present with progressive shortness of breath, thromboembolic complications, arrhythmias, pressure effects, rupture, or even death. Imaging is of paramount importance in establishing an accurate diagnosis, delineating morphology and extent of the lesion along with its hemodynamic significance, planning management, and in the follow-up.

Surgical Repair of a Sinus of Valsalva Aneurysm: A 22-Year Single-Center Experience

BACKGROUND

Several reports described the repair of sinus of Valsalva aneurysms (SVAs); however, there is still debate regarding the optimal method of operation. We investigated the determinants of the development of significant aortic regurgitation (AR) and long-term survival after surgical repair.

METHODS

Between January 1995 and December 2016, 71 patients (31 females; median age: 33.3 years) underwent surgical SVA repair with (n = 60) or without (n = 11) rupture. Aortic valvuloplasty (AVP) was performed using Trusler's technique in 28 patients (39.4%), and 11 patients (15.5%) underwent aortic valve replacement during the first operation.

RESULTS

There was no early mortality, and three deaths occurred during follow-up (median: 65.4 months). Patients with grade II preoperative AR who underwent AVP tended to develop significant postoperative AR, but freedom from significant AR did not differ statistically (p = 0.387). Among patients who underwent AVP, freedom from significant AR did not differ statistically between those with grades I and II and those with grades III and IV (p = 0.460).

CONCLUSION

Surgical repair of SVA with or without rupture can be performed safely using the dual approach technique. Concomitant aortic valve repair can be performed without difficulty and should be recommended not only for patients with moderate or severe preoperative AR (grades III and IV) but also for those with minimal or mild preoperative AR (grades I and II), whose aortic valve geometry needs correction.

Safety and efficacy of percutaneous closure of ruptured sinus of Valsalva aneurysm

AIMS

The aim of this study was to evaluate the safety and efficacy of percutaneous closure in patients with a ruptured sinus of Valsalva aneurysm (RSVA).

METHODS AND RESULTS

A total of 29 patients with RSVA were retrospectively enrolled in our study. All patients were successfully treated by percutaneous closure and had a complete closure at discharge; however, two patients had a trivial procedure-related aortic regurgitation (AR) after the procedure. On a mean follow-up of 29.7±23.8 months (range 1-83 months), the two procedure-related AR disappeared three months and two years after the procedure, respectively. Trivial residual shunt was found in one patient, sinus of Valsalva aneurysm ruptured again in one patient and trivial to moderate AR was found in two patients during the follow-up.

CONCLUSIONS

In appropriately selected patients with RSVA, percutaneous closure is an attractive alternative to surgery with high technical success and good short-term and midterm outcomes; however, long-term follow-up is mandatory.

Ruptured Sinus of Valsalva Aneurysm and Gerbode Defects: Patient and Procedural Selection: the Key to Optimising Outcomes

PURPOSE OF REVIEW

In this review, we reflect on the historical background, clinical features and imaging techniques used to assess Gerbode defects and sinus of Valsalva aneurysms. We aim to review the evolution of treatment strategies and the progression towards less invasive management for these conditions.

RECENT FINDINGS

While transthoracic echocardiography is often diagnostic, transesophageal echocardiography (2D and 3D) has improved our understanding of these defects and allowed us to more accurately define their anatomy. Cardiac MRI provides improved assessment of the physiological impact of defects by quantifying shunt volume. Transcatheter techniques are currently vying with surgery as the mainstay of treatment. New insights are being discovered regarding diagnostic modalities and treatment pathways. Defining criteria for patient selection for catheter or surgical therapy is essential when deciding on the optimum intervention for the individual patient.

Cross-sectional imaging of sinus of Valsalva aneurysms: lessons learned

Sinus of Valsalva aneurysm, dilatation of one or more of the aortic sinuses, is a rare but important aortic root defect, which can be a cause of some serious cardiac sequels. The purpose of this article is to review the etiopathogenesis, relevant anatomy, clinical manifestations, potential complications, multimodality imaging features, and management of this rare but important entity of sinus of Valsalva.

Ruptured Sinus of Valsalva Aneurysm Causing Acute Right Heart and Hepatorenal Failure Requiring Urgent Surgery

A sinus of Valsalva aneurysm is a rare cardiac anomaly that may be congenital or acquired. Very rarely, they present with acute symptoms as a result of rupture into the cardiac chamber. If left untreated, they almost always result in deteriorating cardiac function. We report a patient presenting with acute right heart failure and hepatorenal syndrome requiring urgent surgery and double patch repair.

Long-term failure of Amplatzer plugs in the treatment of aortic pathology

We present two cases of Amplatzer® device deployment that exhibited long-term failure necessitating surgical correction. The first case illustrates recanalization of a ruptured Valsalva aneurysm with worsening aortic insufficiency after percutaneous repair with the Amplatzer Vascular Plugs and Amplatzer duct occluder, while the second case illustrates recanalization after deployment of the Amplatzer septal occluder in a patient with a pseudoaneursym in a bovine aorta after type I aortic dissection repair. These two cases illustrate the potential long-term complications and limitations in durability with these devices.

Severe Dilatation of Coronary Artery Ostium Complicating Sinus of Valsalva Aneurysm: Differential Diagnosis and Review of the Literature

Coronary artery dilatation may be due to various aetiologies including congenital anomalies, atherosclerotic coronary disease, and Kawasakis disease. We describe a case characterised by apparent severe dilatation of the right coronary artery ostium in an asymptomatic male. Subsequent imaging and surgical intervention documented the presence of a sinus of Valsalva aneurysm extending into the ostium of the right coronary artery. This represents an unusual manifestation of a sinus of Valsalva aneurysm. The underlying pathophysiology, differential diagnosis, role of surgical management, and outcomes are discussed.

Aorto-Right Ventricular Fistula Post-Transcatheter Aortic Valve Replacement: Multimodality Imaging of Successful Percutaneous Closure

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Aorto-right ventricular fistula is a rare diagnosis and is on the spectrum of aortic periannular rupture.

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Multimodality imaging is crucial in identifying aortic periannular rupture, defining its course, and for preprocedural planning.

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We describe a case of aorto-right ventricular fistula, which was successfully treated using an Amplazter vascular plug intravenous device (St. Jude Medical) and is to our knowledge the first reported case of using a plugging device for this type of disorder.

Transcatheter Closure of Ruptured Sinus of Valsalva Aneurysm: Report of two cases

A ruptured sinus of Valsalva aneurysm (RSVA) is a rare cardiac anomaly. Traditionally, RSVAs were repaired surgically; however, percutaneous transcatheter closure is the current treatment of choice. We report two cases of RSVA which were closed using this approach. The first case was a 45-year-old female who presented to the Royal Hospital, Muscat, Oman, in 2014 with a RSVA in the right ventricle. The second case was a 39-year-old male who was admitted to the Sultan Qaboos University Hospital, Muscat, in 2015 with a large multifenestrated RSVA extending into the right ventricle outflow tract. Each patient underwent transcutaneous cardiac catheterisation using three-dimensional echocardiography. Both interventions were technically successful; however, the second patient required a subsequent surgery due to the continuing presence of a significant shunt. Transcatheter closure of RSVAs is an effective alternative to surgical repair, although large multifenestrated RSVAs should be repaired surgically to ensure complete closure.

Bacterial Endocarditis Caused by Lactobacillus acidophilus Leading to Rupture of Sinus of Valsalva Aneurysm

Lactobacillus acidophilus rarely causes bacterial endocarditis, because it usually resides in the mucosa of the vagina, gastrointestinal tract, and oropharynx. Moreover, sinus of Valsalva aneurysms are rare cardiac anomalies, either acquired or congenital. We present the case of a middle-aged man whose bacterial endocarditis, caused by Lactobacillus acidophilus, led to an aneurysmal rupture of the sinus of Valsalva into the right ventricular outflow tract. The patient underwent successful surgical repair, despite numerous complications and sequelae.

Chest Pain after Aortic Valve Replacement: Rupture of Right Sinus of Valsalva Presenting as Myocardial Infarction

Background: A 47-year-old male presented with retrosternal chest pain, which had started 4 days previously and had become excruciating for the past 6 h. He had undergone mechanical aortic valve replacement surgery 4 months previously. Investigation: Electrocardiography, echocardiography, computed tomography-angiography of the aorta. Diagnosis: Rupture of the right sinus of Valsalva and right coronary artery dissection. Management: The defect in the right coronary sinus was closed, and the dissection at the root of the right coronary artery was resected and the right coronary artery bypassed to the root of the aorta.

Ruptured Right Sinus of Valsalva Aneurysm Caused by Suspected Takayasu's Arteritis

A sinus of Valsalva aneurysm (SVA) is a rare aortic anomaly. The most common complication is a rupture into the right ventricle and atrium. An SVA rupture into the left ventricle is a rare event. A 42-year-old man visited an outpatient clinic due to worsening exertional dyspnea. A loud to-and-fro heart murmur was detected, and echocardiography revealed a right SVA that had ruptured into the left ventricle, inducing acute heart failure. Computed tomography imaging allowed us to determine that the right SVA had been caused by asymptomatic Takayasu's arteritis. The patient was treated with prednisolone and the right SVA rupture was surgically repaired.

Right Valsalva Sinus Aneurysm Protruding Into the Right Ventricle: A Case Report

A separation between the aortic media and annulus fibrosus causes a rare cardiac abnormality called sinus of Valsalva aneurysm (SVA) that may be congenital or acquired. It is more prevalent in the right coronary sinus (65%-85%) but it has been seen rarely in non-coronary (10%-30%) or Left coronary sinus (<5%). The most common complication is rupture of the Aneurysm. We present an 80-year-old male with expanding right Valsalva sinus aneurysm and protruding into right ventricle. The conventional treatment is surgical repair under cardio-pulmonary bypass or percutaneous catheter closure. The aneurysm was successfully excised surgically under direct guidance of trans-esophageal echocardiography (TEE).

Unruptured sinus of Valsalva aneurysm presenting with concurrent Morgagni hernia

We describe a patient with dyspnea and intermittent cyanosis who was found to have concurrent right diaphragmatic and right atrial masses, initially thought to have advanced vascular sarcoma. She was ultimately diagnosed with an unruptured sinus of Valsalva aneurysm, a Morgagni hernia, and a patent foramen ovale. Her dyspnea and cyanosis resolved after sequential surgical correction of these defects.

Sinus of Valsalva Aneurysm: A Rare Cause of Dyspnea

Sinus of Valsalva aneurysm (SOVA) is a rare clinical entity. Clinical manifestations can vary from an incidental finding on an imaging study to a life-threatening emergency. We report a case of a 51-year-old female with a large symptomatic left SOVA. Echocardiogram and computed tomography angiography (CTA) of the chest revealed marked dilatation of the left sinus of Valsalva, measuring 7.5 cm. This resulted in superior displacement of the left main coronary artery. Surgical repair of the aneurysm with reimplantation of the right and left coronary arteries was performed in addition to aortic valve replacement (Bentall procedure). The patient had an uneventful postoperative course and remains asymptomatic at the three-month follow-up visit.

Imaging unruptured giant aneurysm of right sinus of Valsalva by 320-row dynamic volume computed tomography (CT): a case report

Multi-detector computed tomography with ECG-synchronized data acquisition allows detailed analysis of cardiac anatomy of the heart with excellent spatial resolution. Sinus of Valsalva aneurysms occurs rarely in the western world, but the incidence in Asian populations is higher (Goldberg and Krasnow in Clin Cardiol 13:831-836, 1990). We present the case of a patient with an unruptured giant aneurysm of right sinus of Valsalva.

Cesarean section under epidural anesthesia in a documented case of ruptured aneurysm of the sinus of valsalva

Ruptured aneurysm of sinus of Valsalva (RSOV) occurring in pregnancy is a rare cardiac anomaly and it may be either congenital or acquired. Congenital sinus of Valsalva aneurysms are commonly associated with other structural defects such as ventricular septal defect (50-55%), aortic regurgitation (AR) (25-35%), bicuspid aortic valve (10-15%) and Marfan's syndrome (10%). RSOV in pregnancy accentuates the hemodynamic stress on maternal cardiovascular system and pose a significant challenge from obstetric anesthesia point of view. We report a case of 35-year-old documented patient of RSOV with mild AR presenting completely asymptomatic at 37 weeks 4 days of gestation. A successful elective lower segment cesarean section was conducted under epidural anesthesia.

Progression of aortic regurgitation in Asian patients with congenital sinus of valsalva aneurysm

BACKGROUND

We reviewed the experience of An Zhen and Fu Wai Hospital for congenital sinus of Valsalva aneurysm (SVA) to determine risk factors for aortic valve replacement (AVR) and postoperative progression of aortic regurgitation (AR).

METHODS

Over a 7-year period, 255 patients underwent surgical repair of an SVA. Aneurysms originated from the right sinus and the noncoronary sinus in 212 patients (83.1%) and 38 patients (14.9%), respectively, and protruded into the right ventricle and right atrium in 171 patients (67.1%) and 80 patients (31.4%), respectively. AR presented in 142 patients (55.7%), 60 patients underwent AVR, and 13 patients underwent aortic valvuloplasty (3 patients eventually received AVR for valvuloplasty failure).

RESULTS

All patients survived the operation. Late death occurred in 2 patients (0.8%), and 2 patients (0.8%) experienced anticoagulation-related complications. Logistic regression analysis revealed that infective endocarditis, the cardiothoracic ratio, and a nonruptured SVA were risk factors for AVR. Late follow-up of 150 patients by echocardiographic assessment revealed that AR improved in 17 patients and worsened in 20 patients. Cox regression analysis revealed AR at discharge to be an independent risk factor for AR aggravation at late follow-up.

CONCLUSIONS

SVA can be repaired with low mortality and excellent long-term results. AR at discharge is an important factor in determining AR aggravation at late follow-up after the operation. We recommend early diagnosis and aggressive treatment for SVA.

Perivalvular pseudoaneurysm caused by streptococcus dysgalactiae in the presence of prosthetic aortic valve endocarditis

A 62-year-old man with a medical history of aortic valve replacement was referred to our hospital with high-grade fever. Blood culture was positive for Streptococcus dysgalactiae, and the echocardiogram showed edematous aortic annulus, suggesting a perivalvular abscess. Treatment with antibiotics was started, which showed progressive improvement. The echocardiogram at 2 weeks after admission showed progression of the perivalvular abscess, resulting in the formation of a perivalvular pseudoaneruysm, which revealed rapid enlargement. The patient underwent surgical resection of a 20-mm pseudoaneurysm, originating from the right and left coronary cusp. Complete resection of the infective tissue was performed, and an aortic root replacement was done. This case highlights that a frequent follow-up should be performed in case of perivalvular abscess, because of the risk of pseudoaneurysm formation, which may cause a life-threatening outcome.

Aorta to right atrial shunt due to the rupture of a degenerative aneurysm of the noncoronary sinus of Valsalva

Aneurysms of the sinus of Valsalva are a rare aortic pathology. Congenital aneurysms caused by weakness at the junction of the aortic media and the annulus fibrosus occur more commonly than acquired aneurysms, which are typically secondary to disease processes that involve the aortic root. The both can remain clinically silent for many years. About half are associated with aortic regurgitation. Symptoms can be caused by mechanical obstruction, with compression of the conducting system, or intracardiac rupture. Herein, the case of a 77 years old man, with no specific cardiologic risk factor, who came to our attention with an acute congestive heart failure and a diagnosis of a ruptured aneurysm of the noncoronary sinus of Valsalva is described. After diagnosis was confirmed, he underwent an emergency repair of the lesion.

Gigantic unruptured sinus of Valsalva aneurysm presenting as an incidental murmur

We report a case of a 56-year-old man referred by his family physician with an asymptomatic cardiac murmur. Trans-thoracic echocardiography (TTE) suggested an unruptured right sinus of Valsalva aneurysm (SVA) causing extrinsic compression of the right ventricular outflow tract. This was confirmed with an ECG-gated cardiac CT showing a large right SVA measuring 35×37×42 mm in size. Coronary angiography demonstrated non-obstructive coronary artery disease. Ascending thoracic anterior in the right anterior oblique view delineated the right SVA. The patient underwent aortic valve sparing surgical repair of the aneurysm with an excellent result. Echocardiography confirmed obliteration of the aneurysm and normal aortic valve function postoperatively.

Silent rupture of sinus of Valsalva aneurysm: a refutation of the Okham's razor principle

Aneurysm of the sinus of Valsalva is an uncommon congenital lesion rarely reported in children. Unruptured aneurysms commonly go undiagnosed until a rupture has occurred. Usually, ruptured sinus of Valsalva presents with cardiac failure. There may be a history of trauma or infective endocarditis preceding the rupture. Asymptomatic paediatric presentation of ruptured sinus of Valsalva is rare. We discuss the cases of two children who presented with a murmur and were diagnosed with ruptured sinus of Valsalva. This unusual presentation in children highlights the importance of careful routine physical examinations and the evaluation of new murmurs. The Okham's razor principle states that "when you hear hoofbeats - think horses not zebras". Sometimes, it is important to think beyond the usual in medicine, to avoid missing lesions that, if left untreated, could lead to adverse outcomes.

Emergency surgery for ruptured sinus of Valsalva aneurysms

OBJECTIVES

A ruptured sinus of Valsalva aneurysm is a very rare cardiac anomaly. Successful repair of these aneurysms was first described in the late 1950s. Several approaches for repair, through the aortic root or the chamber into which the aneurysm ruptures or a combination of both, have been described. We present our experience with emergency surgical repair of ruptured sinus of Valsalva aneurysms and our current surgical policy.

DESIGN

A review of the St. Antonius Hospital database from January 1972 to December 2010 identified a total of 16 patients. A retrospective review of their medical records and telephonic follow-up was performed.

RESULTS

Fifteen patients (13 male, three female) aged 46 ? 13 years were operated. The ruptured aneurysm arose from the right coronary (63%) and non-coronary sinus (37%) and ruptured into the right ventricle (67%) and into right atrium (33%). Primary suture closure was done in six patients and patch closure was performed in the remaining 10 patients. No intra-operative death occurred. Long-term follow-up identified one recurrent fistula from right coronary sinus to right atrium 28 years after primary suture closure.

CONCLUSIONS

We performed prompt surgical repair of the ruptured sinus of Valsalva aneurysm preferably with a patch.

Ventricular septal aneurysms in adults: findings of cardiac CT images and correlation with clinical features

BACKGROUND

With the increasing use of multidetector computed tomography (MDCT), the number of incidentally detected ventricular septal aneurysms (VSAs) in adults has increased. However, to date, there are not sufficient well-organized data regarding VSAs in adults on MDCT.

PURPOSE

To evaluate the CT findings of ventricular septal aneurysms (VSAs) in adults and correlate the findings with clinical features.

MATERIAL AND METHODS

We performed a retrospective review of the cardiac CT reports in our electronic database of 3402 patients who underwent ECG-gated cardiac CT scans using a 64-slice multidetector CT or dual-source CT from October 2006 to December 2009 at our institute. Among them, eight patients were diagnosed with a VSA. We evaluated the location, size, and morphology of VSAs on cardiac CT angiographies (CCTAs) and correlated the findings with the clinical features of the patients.

RESULTS

On CCTAs, all eight patients were found to have VSAs in the membranous portion of the interventricular septum and toward the right ventricle. The VSAs were 10-22 mm at their longest diameter and had wide necks. The VSAs were lobulated along the outer margin and were incidental findings in all patients. Four of the eight patients had a conduction abnormality such as first-degree atrio-ventricular block or incomplete right bundle branch block seen on ECG, whereas the other four patients had normal ECGs.

CONCLUSION

VSA in adults is usually detected incidentally. It is seen in the membranous portion of the interventricular septum with a lobulated shape on CCTA. It is occasionally associated with a conduction anomaly.