Aneurysms in the left ventricular outflow tract: clinical presentation, causes, and echocardiographic features

Multimodality delineation of a fistulous ruptured sinus of Valsalva aneurysm: a teaching case report

Background

Ruptured sinus of Valsalva (SOV) is a rare cardiac anomaly with poor prognosis if untreated. Early diagnosis with accurate delineation of its anatomy is critical for timely treatment and choice of surgical vs. percutaneous intervention. Here we report a case of fistulous rupture of SOV; the preoperative multimodality studies including echocardiography, cardiac magnetic resonance and cardiac catheterization provided teaching and learning points.

Case summary

A 48-year-old man with history of heart murmur and hypertension presented with a 5-day history of shortness of breath and peripheral oedema. He was diagnosed with rapid atrial flutter. The transthoracic and transesophageal echocardiography showed severe biventricular systolic dysfunction with a left-to-right shunt from ruptured SOV. The colour Doppler by transthoracic and transesophageal echocardiography and cardiac magnetic resonance revealed a swaying shunt flow exiting in direction to the right atrium (RA) and basal right ventricle (RV) during systole and diastole with no myocardial scaring. The left and right heart catheterization showed elevated right-sided pressures, pulmonary capillary wedge pressure, and left ventricular end-diastolic pressure. There was no difference in O2 saturation between venae cavae and RA but a misleading step-up in O2 saturation between RA and RV. Owing to rupture anatomy with uncertainty, the patient underwent surgical intervention. The ruptured SOV tunnelled through the base of tricuspid annulus to the RA very close to the basal RV.

Discussion

Even with multimodality studies it can still be challenging to delineate the anatomy of a ruptured SOV without uncertainty preoperatively.

Association of ruptured sinus of Valsalva aneurysm and congenital ventricular septal defect: a case series

Background

Ruptured sinus of Valsalva aneurysm (RSOVA) is rare, and it is more common in Asians. Typically, the patient presents with acute/subacute shortness of breath (SOB) and chest pain. Echocardiography is the gold standard for diagnosis in most of these cases. Surgery has remained the first line of management.

Case summary

We present two cases of RSOVA in which the patients presented to the emergency department with SOB. Their preoperative echocardiography results showed RSOVA into the right ventricle. During surgical repair, ventricular septal defect (VSD) was also found.

Discussion

RSOVA is frequently associated with other congenital anomalies, and most often with VSD. In our cases, we believe that VSDs were missed preoperatively because either the large aneurysmal sacs covered the VSD or there was overlap between the two shunts. Additionally, in the first case, right ventricular pressure was high approaching systemic pressure, which probably reduced the shunt across the VSD. Early intervention is recommended to prevent endocarditis or enlargement of the ruptured aneurysm; long-term results were excellent after surgical repair. Most patients undergo surgery between 20 and 40 years of age, and the reported survival rate is 95% at 20 years. If left untreated, patients typically die of heart failure or endocarditis within 1 year after onset of symptoms.

Clinically isolated aortitis presenting as inferior ST-elevation myocardial infarction due to an unruptured sinus of Valsalva aneurysm: a rare and forgotten cause of acute coronary syndrome in a young patient with no evidence of systemic vasculitis

A 21-year-old man presented with chest pain, diaphoresis and dyspnoea. Electrocardiogram (ECG) showed inferior ST-elevation myocardial infarction. Troponin I was positive. Patient underwent left heart catheterisation, which revealed normal epicardial coronary arteries except for right coronary artery which could not be engaged. CT coronary angiogram was done, which revealed large right sinus of Valsalva aneurysm giving rise to a pinched out right coronary artery. Patient underwent composite graft replacement of aortic valve, aortic root and ascending aorta along with a saphenous vein graft to right coronary artery. He was discharged in stable condition on fifth postoperative day. Biopsy of the aneurysmal tissue was suggestive of vasculitic aetiology. There was no evidence of systemic vasculitis and Magnetic Resonance Angiography (MRA) screen was negative for Takayasu's arteritis. Our patient was, hence, diagnosed with clinically isolated aortitis leading to ST elevation myocardial infarction due to an unruptured sinus of Valsalva aneurysm.

Giant aneurysmal of the left sinus of Valsalva in adults

OBJECTIVE

To investigate the aneurysmal of the left sinus of Valsalva, and to improve the understanding of the disease and the level of diagnosis and treatment.

METHOD

This article mainly reports a case of a huge aneurysmal of the left sinus of Valsalva patients treated with surgical treatment.

RESULT

After surgery, the prognosis of the case was good.

CONCLUSION

Aneurysmal of the left sinus of Valsalva has a low incidence, which is rare in clinical with no clinical specific symptoms leading to difficulty in early detection. The appropriate surgical method should be considered to the patient's condition, to prevent the tumor rupture and the death of patients.

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.

Unusual Lesions of the Mitral Valve: Two Different Conditions with the Same Imaging Findings

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Mitral valve (MV) aneurysms are unusual lesions, its incidence is 0.02% to 0.29%.

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Most cases of MV aneurysms are a complication of aortic valve endocarditis.

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Direct Infection of MV leaflets and degenerative lesions could cause a MV aneurysms.

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MV aneurysms are rarely surgical complication, however, it should be kept in mind.

Ruptured Sinus of Valsalva: An Unusual Cause of Heart Failure

A 35-year-old male patient presented with heart failure. On examination, there was a continuous murmur over the left sternum. Transthoracic echocardiography revealed a ruptured aneurysm arising from the noncoronary sinus of Valsalva and draining into the right atrium.

Isolated Aneurysms of the Membranous Ventricular Septum Without Residual Shunts: Systematic Review and Description of 3 Cases in Adults

A ventricular septal defect is the most common congenital cardiac abnormality encountered in infants and children. Many of them survive through adulthood before diagnosis. Two-thirds of the cases involve the membranous part of the septum. In the absence of an interventricular shunt or concomitant cardiac surgery, guidelines for surgical intervention or resection of isolated aneurysms of the membranous septum are not well established. In this report, we discuss a multi-imaging modality approach for the diagnosis and assessment of membranous ventricular septal aneurysms and review the experts' consensuses for follow-up and treatment strategies.

A giant aneurysm of noncoronary sinus of Valsalva concomitant with aortic regurgitation and mitral regurgitation

Aneurysms of the sinus of Valsalva (ASV) are rare, with an incidence ranging from 0.1% to 3.5% of all congenital cardiac defects and a prevalence of 0.009% in an autopsy series.ASVs occur much more frequently in the right coronary sinus of Valsalva. Previous reports, based on necropsy and cardiac surgery findings, estimated that 20% of ASVs are unruptured. Patients with an unruptured ASV may remain asymptomatic for a long period of time until rupture. They may also presented with dyspnea, palpitation, and angina-like chest pain. Aortic insufficiency in the patients with unruptured ASVs is common, and other valvular lesions can be observed in these patients as well. Echocardiography, as a noninvasive and portable tool, is widely used to detect ASVs. Additionally, computed tomography and cardiac magnetic resonance imaging, alone or in combination, can provide precise information about its anatomic extension and intrinsic characteristics of the pathology.

Surgical treatment of a giant unruptured aneurysm of the noncoronary sinus of Valsalva: a case report

Background

A sinus of Valsalva aneurysm is a rare cardiac anomaly which may be acquired or congenital. The main associated symptoms are conduction disturbances, myocardial ischemia, and syncopes.

Case presentation

In this report we describe a 52-year-old Albanian woman from Kosovo with an unruptured aneurysm of 74×60 mm of the noncoronary sinus of Valsalva presenting dyspnea, jugular distension, and tachycardia due to cardiac compression. She underwent successful closure of the orifice and sinus remodeling with a Dacron patch.

Conclusion

To the best of our knowledge this is the largest reported isolated unruptured aneurysm of the coronary sinus causing severe compression of the cardiac chambers undergoing successful surgical correction.

Aortic root remodeling and external aortic annuloplasty to treat sinus of Valsalva aneurysm in a patient with complete situs inversus

BACKGROUND

Sinus of Valsalva aneurysm is an uncommon anomaly of the aorta. It occurs most frequently in the right sinus of Valsalva. Complications depend on its size and location. Situs inversus totalis is a rare condition wherein organs are reversed from their normal positions (mirror image).

CASE PRESENTATION

We report the case of a 69-year-old man who presented situs inversus totalis known since his childhood and a sinus of Valsalva aneurysm in the right coronary sinus discovered by echocardiography following a history of infection. This was confirmed by CT-scan and MRI. Valve sparing surgery was performed using the remodeling technique associated with external aortic annuloplasty

CONCLUSIONS

The remodeling technique with exteranl aortic annuloplasty is usual technique to treat SVA.

Very late recurrence of sinus of Valsalva aneurysm rupture after patch repair

Background

Sinus of Valsalva aneurysm (SVA) is an uncommon cardiac defect accounting for only 1% of congenital cardiac anomalies and the most common complication is ruptured into the atrium or ventricle. Very late recurrence of ruptured SVA after patch repair is extremely rare.

Case presentation

We present a case of 57-year-old man had received repair for ruptured Sinus of Valsalva aneurysm at 19 ages. In the clinics, he presented with exertional dyspnea and leg swelling. The serial examination disclosed he had bicuspid aortic valve and very late rupture of SVA connecting to right atrium. After surgical repair again, he was discharged smoothly.

Conclusion

A very late recurrence of ruptured SVA after surgical repair was rare. We reported a case with unique echocardiographic presentation and a successful repair.

Bad company: supracristal VSD presenting with ruptured sinus of valsalva aneurysm. a case presentation with echocardiographic depiction and an analysis of contemporary literature

Supracristal ventricular septal defect (SCVSD), a defect of the infundibular portion of the interventricular septum just below the right aortic cusp, occurs more frequently in Eastern Asian populations. SCVSD may be complicated by right sinus of Valsalva aneurysm (SoVA). We present the case of a 26-year-old male of Korean descent with a history of a childhood murmur who was referred to our institution for progressive heart failure symptoms. He was diagnosed with SCVSD and ruptured right SoVA based on history, physical exam, and echocardiography including three-dimensional transesophageal echocardiography with reconstructed surgical views. The patient underwent SCVSD closure, SoVA excision, and valve-sparing aortic root replacement. We reviewed the echocardiography literature regarding SCVSD and SoVA, and analyzed contemporary literature of SoVA and its relationship with SCVSD. We conclude that a higher prevalence of ruptured SoVA in Eastern Asians is likely related to a higher prevalence of underlying SCVSD in this population.

[Large aneurysm of the left sinus of Valsalva in a 54-year-old man successfully treated with surgery]

Sinus of Valsalva aneurysms are very rare and are often asymptomatic. Clinical manifestations depend on associated complications, most commonly rupture or dissection. We describe the case of a 54-year-old male presenting with exercise-related angina and dyspnea and in whom we found a large unruptured aneurysm of the left sinus of Valsalva. On angiography, he also had a severe stenosis of the left artery descending and the diagonal. He underwent a successful surgical intervention with bypass and closure of the aneurysm.

Sarcoidosis or acute coronary syndrome: Easily distinguishable?

Sinus of Valsalva aneurysm is a rare presenting feature of ST-elevation myocardial infarction. We describe such a case which resolved with thrombolysis, and on further investigation, the patient was found to have a large sinus of Valsalva aneurysm. Abnormal gross pathology at the time of surgery was suspected to be aortitis which was only confirmed on postmortem examination 6 months later. We highlight the importance of working closely with a pathologist when aortitis is suspected, because failure to treat it medically results in a poor outcome.

Two different presentations of sinus of valsalva aneurysm

Sinus of Valsalva aneurysm (SVA) is a rare cardiac anomaly that can be congenital or acquired. We report 2 cases of SVA. The first case involves a 59-year-old male presenting with frequent syncope. Echocardiogram revealed a large right SVA obstructing the right ventricular outflow tract (RVOT). The second case involves a 21-year-old female presenting with sudden onset chest pain and a continuous machinery murmur. Echocardiogram revealed a ruptured right SVA into the right atrium. Although advanced percutaneous techniques have been implemented in the correction of this anomaly, open-heart surgery with or without aortic valve replacement remains the treatment of choice.

Valsalva aneurysm filled with thrombi mimicking a cardiac tumor

A Valsalva aneurysm filled with thrombi can be difficult to diagnose, because it mimics a cardiac tumor. Both cardiac magnetic resonance imaging (MRI) and transesophageal echocardiogram (TEE) were performed on a patient who showed a low-echoic mass located between the atrial septum and the non-coronary sinus. Based on MRI findings allowing tissue characterization and the accurate location of the mass and the TEE findings of an irregular surface of the mass and a partial defect in the edge of the non-coronary sinus, we diagnosed the mass as a thrombosed Valsalva aneurysm that had perforated the inter-atrial septum. The operative findings coincided with the preoperative diagnosis. Both MRI and TEE are useful for diagnosing this condition.

Ruptured right sinus of Valsalva into main pulmonary artery

A young adult who presented with congestive heart failure was found to have ruptured aneurysm of right sinus of Valsalva. The aneurysm was opening into the main pulmonary artery, which was demonstrated well by transthoracic and transesophageal echocardiography and confirmed by cardiac catheterization. Aneurysm was repaired followed by aortic valve replacement.

Interatrial rupture of a non-coronary sinus of Valsalva aneurysm: a rare presentation of a rare disorder

A 65-year-old male was referred to our team after the incidental finding of a large non-coronary sinus of Valsalva aneurysm on computed tomography (CT)-scan of the thorax. Further imaging with transesophageal echocardiography (TOE) excluded intracardiac shunting. Unusually, the aneurysm had ruptured into the interatrial septum and was seen to be compressing both atria. At operative intervention, a 20 mm defect which had replaced the non-coronary sinus was repaired using a patch graft. An aneurysm of an aortic sinus is a rare disorder, and a rupture of a non-coronary sinus typically results in the formation of a fistulous tract in the right atrium. These images highlight an unusual case of a non-coronary sinus of Valsalva aneurysm which ruptured into the interatrial septum (IAS), and demonstrate the benefit of multi-modality cardiac imaging in guiding surgical repair.

Sinus of valsalva aneurysm in Blau's syndrome

Blau syndrome is a rare granulomatous disorder inherited in an autosomal dominant manner characterized by the early appearance of granulomatous arthritis, skin rash and anterior uveitis. There are very few data on the cardiovascular manifestations of Blau syndrome. Here we report the first case of sinus of valsava aneurysm in Blau syndrome. In isolated unruptured aneurysms of a sinus of Valsalva without compromise of the aortic valve and/or the coronary ostia, repair may be accomplished by simple placation of the aneurysm or excision of the aneurysm(s) and patch closure of the defect(s) between the aortic annulus and the sinu-vascular ridge. Because of the particular conditions in our case, the repair was performed with replacement of the aortic valve and root using a composite graft employing a modified Bentall's technique.

Mitral Valve Aneurysm With Infective Endocarditis

A case of mitral valve aneurysm associated with infective endocarditis is reported. Two-dimensional echocardiography revealed a saccular structure in the anterior leaflet that bulged into the left atrium throughout the cardiac cycle. During operation, the vegetation on the commissure of the right and left aortic leaflet and a 3-mm perforation on the noncoronary leaflet were found. The mitral valve and aortic valve were replaced with mechanical prosthesis. Pathology of the excised valves showed inflammation. For this patient, we considered that the infected aortic regurgitant jet striking the ventricular surface of the anterior mitral leaflet could be the mechanism of the leaflet aneurysm.

Delayed presentation of left ventricular outflow tract aneurysm after penetrating cardiac trauma

We report a case of posttraumatic left ventricular outflow tract aneurysm in a patient who had a stab injury to the chest requiring emergency operation 40 years previously. After apparent decades without symptoms, the patient presented with exertional dyspnea. Clinical and echocardiographic assessment revealed aortic regurgitation and left ventricular outflow tract aneurysm. Injuries to the chest wall that penetrate the heart and great vessels are life-threatening and require emergency operative intervention. However, these injuries rarely, as in this case, result in chronic cardiac aneurysm and aortic valvular incompetence.

Giant aneurysm of the membranous ventricular septum extending outside the heart: diagnosis by transthoracic color flow Doppler echocardiography

Aneurysm of the membranous ventricular septum (AMS) is a congenital cardiac anomaly often associated with ventricular septal defect. This aneurysm usually pouches into the right side of the heart and remains intracardiac. An AMS that extends outside of the heart is rare. We report an unusual case of a giant extracardiac AMS diagnosed by transthoracic color flow Doppler echocardiography.

Anterior mitral valve aneurysm: a subaortic complication of aortic valve endocarditis: a case report and review of literature

Mitral valve aneurysm is a rare cause of mitral regurgitation, and is usually associated with aortic valve endocarditis. Prompt diagnosis and early surgical treatment can prevent complications such as embolization and rupture of the aneurysm. The authors report a case of aortic valve endocarditis and mitral valve aneurysm in a patient who initially presented with urinary tract infection.

Imaging of an aneurysm of the sinus of Valsalva with transesophageal echocardiography, contrast angiography and MRI

A sinus of Valsalva aneurysm is an uncommon congenital defect, which requires appropriate diagnosis with either echocardiography, magnetic resonance imaging or contrast angiography. Treatment consists of aortic valve repair. We describe a young woman with an aneurysm of the non-coronary sinus of Valsalva, an atrial septal defect and pulmonary insufficiency. The different imaging techniques and possibilities of surgical correction are described.

Clinical, anatomic, and echocardiographic characteristics of aneurysms of the mitral valve

This study describes the clinical, anatomic, echocardiographic, and Doppler features of 13 patients with mitral valve aneurysms. Eleven patients had definitive criteria for infective endocarditis. Transesophageal echocardiography was superior to conventional echocardiography in detecting and assessing aneurysms. Patients with heart failure required surgery. Echocardiographic detection of this lesion should not be, by itself, an immediate surgical indication.