Sinus of Valsalva Pseudoaneurysm
A 59-year-old woman presented with exertional dyspnea this past year. She gave no history of cardiac disease or trauma. On examination, a soft systolic ejection murmur was noted at the left sternal border. Her blood pressure was 110/74 mm Hg, and her pulse rate was 84 bpm. The ECG showed a normal sinus rhythm with T-wave inversion in leads II, III, and aVF. Roentgenography of the heart revealed mild cardiomegaly. Two-dimensional transthoracic echocardiography demonstrated a huge cystic mass (9.4×8.3 cm) with a ball-like thrombus next to the aortic root extending into the right ventricular outflow tract (Fig 1⇓). Doppler color flow mapping showed a turbulent flow in this cystic mass (Figs 2⇓ and 3⇓). Rupture of the sinus of Valsalva with pseudoaneurysm formation was diagnosed. During right heart catheterization, the mean right atrial pressure was 11 mm Hg, the right ventricular pressure was 24/5 mm Hg, the main pulmonary artery pressure was 15/6 mm Hg, and the right pulmonary artery wedge pressure was 7 mm Hg. During left heart catheterization, her aortic pressure dropped from 110/70 to 55/35 mm Hg, and the patient became drowsy. For fear of sudden rupture of the aortic pseudoaneurysm, the patient was immediately transferred to the operating room for open-heart surgery. During surgery, a huge, pulsating mass was noted over the right ventricular free wall extending into the aortic root and causing compression of the right ventricular outflow tract. It was an aneurysm originating from the right coronary sinus, and the aneurysm ruptured into the right ventricular free wall between the epicardium and myocardium. A 5×4×4-cm thrombus was noted within the aneurysm. No ventricular septal defect was found. The aneurysm was resected, and the rupture site was repaired with a pericardial patch. Microscopic examination of the resected tissue showed an atherosclerotic aorta with a false aneurysm formation in the adventitial area. After the operation, the patient did well.
Reprint requests to Dr Chiau-Suong Liau, Department of Internal Medicine, National Taiwan University Hospital, No. 7 Chung-Shan S Rd, Taipei, 10002, Taiwan.
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.
Circulation encourages readers to submit cardiovascular images to Dr Hugh McAllister, Jr, St Luke’s Episcopal Hospital and Texas Heart Institute, 6720 Bertner Ave, MC1-267, Houston, TX 77030.
- Copyright © 1998 by American Heart Association