Sinus of Valsalva Aneurysms
A Unique Case of Giant Aneurysms Involving All 3 Sinuses
A 59-year–old male was admitted through the emergency room after falling from a ladder at a height of 12 feet. He sustained multiple fractures including a complicated proximal humeral and radial fracture. His cardiovascular physical examination was significant for a 2/4 diastolic murmur. His admission ECG (Figure 1) showed sinus rhythm with a heart rate of 59 bpm, first degree atrioventricular block and premature atrial contractions. His portable chest x-ray (Figure 2) was significant for cardiomegaly, multiple rib fractures, and multiple calcifications projecting over the cardiac silhouette. Because of these abnormal findings and in preparation for his orthopedic surgery, the patient underwent a transthoracic echocardiogram, which revealed a massively enlarged aortic root with large sinuses of Valsalva aneurysms measuring ≈10 cm in diameter (Figure 3). Moderate to severe aortic regurgitation was present, and left ventricular function was normal. The patient was further evaluated by computerized tomography of the ascending aorta (Figure 4A and 4B). This imaging modality further confirmed the findings in the echocardiogram. The presence of a layered thrombus was also noted within the dilated sinuses. Because of these features, the coronary arterial anatomy was not reliably imaged.
Further investigation revealed a previous aortogram done 3 years previously at a different institution where the patient presented with complaints of mild nonexertional chest discomfort that later subsided. This previous study revealed similar findings of a dilated aortic root that already existed at that time (Figure 5 and online-only Data Supplement movie). These findings were not previously known by the patient.
The patient denied any signs or symptoms of cardiac ischemia or embolic complications such as stroke. Despite recommendations for aortic surgery, the patient refused a corrective procedure. Subsequently, the patient underwent surgical repair of his fractures without complication.
Aneurysms of the sinus of Valsalva are very uncommon, with an incidence ranging from 0.1 to 3.5% of all congenital heart defects. Such aneurysms account for only 0.14% of all open heart surgical procedures.1 Aneurysms of the sinus of Valsalva are usually diagnosed as an incidental finding or after an acute rupture into an adjacent cardiac structure. Before 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.2
Sawyers et al demonstrated a mean survival period of 4 years in patients with untreated ruptured sinuses of Valsalva aneurysms, a finding that favors the need for early surgical intervention in this group.3 The optimal management of an asymptomatic, nonruptured aneurysm is less clear because of the absence of a precise natural history.4 Improvements in surgical technique in the past 15 years have resulted in low complication rates with no early mortality (0%) and low morbidity (4%).4
To our knowledge, only 2 cases have been reported in the literature that presented with involvement of ≥2 sinuses.5,6 This is a unique case of aneurysms of all 3 coronary sinuses presenting with no clinical signs or symptoms. Despite being asymptomatic and having a favorable course thus far, we recommended that our patient have surgery performed as soon as possible to minimize the risk of future cardiovascular events.
The online-only Data Supplement, consisting of a movie, is available with this article at http://circ.ahajournals.org/cgi/content/full/117/15/e308/DC1.