Large Unruptured Aneurysm in Sinus of Valsalva
An Unusual Cause of Right Ventricular Inflow and Outflow Tract Obstruction
A 64-year-old man with a large cavitating squamous cell carcinoma (6×6 cm) in the right lower lobe of the lung was referred for prelobectomy cardiac assessment because of incidental finding of Q waves in leads II, III, and aVF on the ECG. Physical examination revealed an ejection systolic murmur at the left sternal edge. Cardiac size was normal on chest radiograph. A transthoracic echocardiogram revealed a large cavity at the aortic root, 5 cm in diameter, obscuring visualization of the right heart (Figs 1⇓ and 2⇓). Diagnostic cardiac catheterization was performed. An aortogram revealed a large (5×5 cm), unruptured aneurysm in the sinus of Valsalva arising from the right coronary sinus (Fig 3⇓), and a coronary angiogram showed normal anatomy. A right ventricular angiogram demonstrated obstruction at the inflow and outflow tracts of the right ventricle due to compression from the aneurysm (Fig 4⇓). There was a 20 mm Hg pressure gradient across the right ventricular outflow tract. Therefore, a large, unruptured aneurysm in the sinus of Valsalva may be an unusual cause of right ventricular inflow and outflow tract obstruction.
The editor of Images in Cardiovascular Medicine is Hugh A. McAllister, Jr, MD, Chief, Department of Pathology, St Luke’s Episcopal Hospital and Texas Heart Institute, and Clinical Professor of Pathology, University of Texas Medical School and Baylor College of Medicine.
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