Sinus of Valsalva Aneurysm With Right Ventricular Outflow Tract Obstruction
Evaluation With Doppler, Real-Time 3-Dimensional and Contrast Echocardiography
A 78-year-old man presented with new exertional dyspnea. Physical examination demonstrated a parasternal thrill that was associated with a systolic murmur, and mild edema of the lower extremities. Transthoracic 2-dimensional and real-time 3-dimensional echocardiography demonstrated a 5.3×4.5-cm aneurysm of the right sinus of Valsalva (Figures 1 and 2⇓ and Movie I). There was moderate to severe aortic regurgitation. The aneurysm protruded into the right ventricular outflow tract, and color Doppler showed turbulent flow around the aneurysm with a peak systolic pressure gradient of 49 mm Hg (Figure 3 and Movie II). Imaging after intravenous injection of perflutren ultrasound contrast agent demonstrated the partition of the right ventricle by the aneurysm (Figure 4 and Movie III). When injected into a peripheral vein, the contrast was seen to opacify the right heart, the left atrium, and then the left ventricle. Finally, the contrast was seen to fill the ascending aorta and the body of the aneurysm (Figure 4 and Movie III). The timing of contrast appearance proved that the aneurysm communicated with the aorta but not with the pulmonary artery.
The patient underwent elective repair of the aortic aneurysm with a prosthetic patch. The patient’s aortic valve was replaced with a pericardial bioprosthesis. Intraoperatively, the aneurysm neck was shown to be distinct from the right coronary artery ostium, and therefore, button excision and reimplantation of the right coronary artery were not required. He was discharged home on the sixth postoperative day, and on a subsequent outpatient visit reported that his shortness of breath had significantly improved.
Aneurysms of the sinus of Valsalva are rare anomalies that are usually diagnosed after an acute rupture into an adjacent cardiac structure. Prior to rupture, aneurysms of the sinus of Valsalva may present with conduction-system abnormalities attributable to erosion into the interventricular septum, thromboembolism originating in the aneurysm sac, and myocardial ischemia attributable to coronary compression.1 Clinically significant right ventricular outflow tract obstruction from a sinus of Valsalva aneurysm is uncommon, with only 2 previously published cases found in the literature.2,3 Two-dimensional Doppler echocardiography easily makes this diagnosis, but real-time 3-dimensional echocardiography allows for complete visualization of the aneurysm neck and its relation to the surrounding structures, including the aortic valve. To our knowledge, preoperative evaluation of the unruptured aneurysm of the sinus of Valsalva with transthoracic real-time 3-dimensional echocardiography has not previously been described. The use of intravenous echo contrast in this case allowed us to prove that the structure in the right ventricular outflow tract was vascular. Echo contrast consists of lipid microspheres filled with an inert fluorocarbon gas. Unlike relatively large bubbles of agitated saline, the smaller bubble size of dedicated ultrasound contrast allows for transpulmonary passage of the agent and imaging of the left-sided structures.
Dr Gelfand serves on the Speaker’s Bureau for Pfizer. Dr Johnstone served on the Speaker’s Bureau for Wyeth and AstraZeneca. Ms. Bzymek has no conflicts of interest to disclose.
The online-only Data Supplement, which contains movies, can be found at http://circ.ahajournals.org/cgi/content/full/115/2/e16/DC1.