Extracardiac Unruptured Sinus of Valsalva, Coronary, and Intracranial Aneurysms
A 65-year-old woman presented for chronic cough and dyspnea with an aortic diastolic murmur. Transesophageal echocardiogram revealed a large, 57-mm nonruptured extracardiac aneurysm of the noncoronary sinus of Valsalva with mild aortic regurgitation. Coronary angiogram showed further multiple aneurysms of the entire coronary arteries (Figure 1). Cardiac MRI (Figure 2) elucidated the anatomy of the aneurysm. Cerebral angiography demonstrated large saccular aneurysms of the left anterior choroidal artery and the intrapetrous right internal carotid artery at the C4-C5 junction (Figures 3 and 4⇓). Both internal carotid and posterior cerebral arteries displayed dysplasia. No visceral aneurysms were detected. A thorough laboratory workup returned negative results, including infectious agents, hypereosinophilia, P-ANCA and C-ANCA, HLA B5, HLA B12, and HLA B27.
Via a median sternotomy, a thin-walled 6×5-cm aneurysm was found lying between the aortic root and the right atrium, laminating the latter (Figure 5). The other sinuses of Valsalva, the aortic root, and the ascending aorta were normal. Cardiopulmonary bypass was initiated between the ascending aorta and the right atrium. Intermittent cold-blood retrograde cardioplegia was used. The aneurysm was opened vertically to provide access to the aortic valve. The aortic annulus was deformed, and the aortic cusps showed dystrophic changes. The valve was replaced with a 21-mm pericardial bioprosthesis with interrupted pledgetted sutures, and the aortic defect was closed with a Dacron patch. The postoperative course was uneventful.
Pathological examination revealed no vasculitic syndrome or eosinophilic infiltration of the aortic wall. Control echocardiography at 1 year showed normal aortic diameter with normal sinuses of Valsalva.