Angina pectoris and sinus of Valsalva aneurysm: a rare manifestation of an uncommon disease

Systolic Ejection Murmurs Due to Unruptured Aneurysm of the Sinus of Valsalva

Aneurysm of the sinus of Valsalva is a rare condition with variable clinical presentation. We present a case of an unruptured aneurysm of the right sinus of Valsalva, in which a systolic ejection murmur was instrumental in the diagnosis. An asymptomatic 72-year-old man was referred to the cardiology department because of a heart murmur. Physical examination was unremarkable except for a grade 3 systolic murmur, loudest at the third left sternal border. Echocardiography revealed a sac-like structure protruding into the right ventricle and attached to the right sinus of Valsalva with a right ventricular outflow tract obstruction during end-systole. Multidetector computed tomography showed an aneurysm of the right sinus of Valsalva with a diameter of 28 × 19 mm; no contrast leakage from the aneurysm was detected. A diagnosis of an unruptured aneurysm of the right sinus of Valsalva was made. Surgical repair was successfully performed, and the murmur disappeared postoperatively. This case underscores the importance of physical examination even in the era of advanced imaging techniques and the need to recognize the wide range of causes of heart murmurs.

Case report: Unruptured sinus of Valsalva aneurysms causing postural angina pectoris and false "pulmonary hypertension"

A 37-year-old woman presented with worsening intermittent chest pain and dyspnea in the previous year. Although the dyspnea was exertion-dependent, her chest pain was heavily dependent on her postural position, worsening in the supine position but alleviated by lying prone or by sitting up and leaning forward. She was cyanotic, and a diastolic murmur in the left third intercostal space was auscultated. An electrocardiogram recorded when she laid flat and had angina pectoris attacks showed ST-segment elevation in the aVR and depression in the II, III, aVF, and V3-V6 leads. However, when she sat up for a few minutes, her symptoms and ST-segment abnormalities disappeared. Echocardiography and cardiac computed tomography angiography revealed large unruptured aneurysms of the left and non-coronary sinuses, along with a dilated aortic root, severe aortic regurgitation, and right ventricular high pressure. Coronary angiography showed ∼90% pulsating stenosis of the left main coronary artery and ∼80% pulsating stenosis of the proximal left circumflex artery, presumably caused by pulsation of the dilated sinus of Valsalva aneurysm under blood pressure. Genetic testing revealed c.1781 C > G nonsense mutations in the FLNA gene. The patient underwent surgery, which confirmed dual unruptured left/non-coronary sinus of Valsalva aneurysms. Our case illustrates an unusual postural form of angina pectoris and false "pulmonary hypertension" caused by large dual unruptured left/non-coronary sinus of Valsalva aneurysms.

Case Report: Extrinsic Compression of the Left Main Coronary Artery by a Giant Sinus of Valsalva Aneurysm

Sinus of Valsalva aneurysm (SoVA) is an uncommon clinical entity, which is present in roughly 0. 09% of the general population. The cause can either be acquired or congenital. Clinically the SoVA of unruptured status are rarely captured or even diagnosed due to atypical clinical presentations. Here, we present a rare case of exertional angina pectoris and recurrent syncope due to an extrinsically compressed left coronary artery by a giant SoVA in a 50-year-old female patient. This SoVA was successfully repaired by the surgical exclusion and the patient was still doing well after 2 years of follow-up.