Aneurysms of sinus of Valsalva: two-dimensional echocardiographic diagnosis and recognition of rupture into the right heart cavities

Hematoma in Epicardial Fat From Sinus of Valsalva Aneurysm

Hematoma in epicardial fat is a rare finding on noncontrast computed tomography imaging. We describe a case with hematoma in epicardial fat that helped to diagnose an oozing, ruptured mycotic sinus of Valsalva aneurysm. (Level of Difficulty: Advanced.)

A Case of Perimembranous Ventricular Septal Defect Associated with Sinus of Valsalva Aneurysm Mimicking Membranous Septal Aneurysm

Sinus of Valsalva aneurysms are rare. Sinus of Valsalva aneurysms are frequently associated with ventricular septal defect (VSD) and aortic regurgitation. They often remain asymptomatic until abruptly presenting with acute chest pain and heart failure secondary to rupture. Here, we describe a case of 20-year-old man who presented with chest pain with a history of VSD. Initial work-up concluded that the patient had VSD associated membranous septal aneurysm. Four years later, the patient presented with symptoms of heart failure. Work-up showed that the ruptured sinus of Valsalva aneurysm was the cause of symptoms. Due to its close proximity to the aortic annulus, sinus of Valsalva aneurysm should be differentiated from membranous septal aneurysm.

A case of unruptured aneurysm of the right sinus of valsalva with right ventricular outflow obstruction

A 66-year-old man presented with exertional dyspnea. He was found to have an unruptured aneurysm of the right sinus of Valsalva causing significant right ventricular outflow obstruction. This aneurysm was diagnosed by transthoracic two-dimensional echocardiography, transthoracic three-dimensional echocardiography, transesophageal echocardiography, contrast echocardiography and 64-slice multidetector cardiac computed tomography. Because unruptured aneurysms of the sinus of Valsalva are rarely symptomatic, they can be difficult to detect. However, the unruptured aneurysm of the right sinus of Valsalva in this case caused significant right ventricular outflow tract obstruction, resulting in exertional dyspnea.

Two different presentations of sinus of valsalva aneurysm

Sinus of Valsalva aneurysm (SVA) is a rare cardiac anomaly that can be congenital or acquired. We report 2 cases of SVA. The first case involves a 59-year-old male presenting with frequent syncope. Echocardiogram revealed a large right SVA obstructing the right ventricular outflow tract (RVOT). The second case involves a 21-year-old female presenting with sudden onset chest pain and a continuous machinery murmur. Echocardiogram revealed a ruptured right SVA into the right atrium. Although advanced percutaneous techniques have been implemented in the correction of this anomaly, open-heart surgery with or without aortic valve replacement remains the treatment of choice.

Large, unruptured, non-coronary sinus of Valsalva aneurysm

We report the case of a 73-year-old previously fit man who presented with a 10-month history of worsening dyspnoea on exertion. Transthoracic echocardiography showed a mass in the right ventricle. The diagnosis of non-coronary sinus of Valsalva aneurysm was confirmed by cardiac magnetic resonance imaging. The patient underwent surgical removal of the aneurysm with uneventful recovery. Since this rare anomaly may arise from different aetiological backgrounds, it is important to consider this condition in the differential diagnosis and diagnostic process in order to deliver prompt, and potentially life-saving, treatment.

Aneurysms of the Sinuses of Valsalva

Sinus of Valsalva aneurysms are rare cardiac anomalies which may be acquired or congenital, most commonly involving the right or noncoronary sinuses. The congenital aneurysms are more common and often caused by weakness at the junction of the aortic media and the annulus fibrosus. Acquired aneurysms are caused by conditions affecting the aortic wall, such as infections (syphilis, bacterial endocarditis, or tuberculosis), trauma, or connective tissue disorders. Unruptured aneurysms are usually found incidentally during diagnostic studies. More commonly, sinus of Valsalvaaneurysms are diagnosed after clinical sequelae of rupture. Diagnosis of sinus of Valsalva aneurysm is facilitated by echocardiography, contrast aortography, and more recently, magnetic resonance imaging. Repair is generally required for ruptured aneurysms; unruptured aneurysms encroaching on nearby structures, causing myocardial ischemia, or having the potential to rupture warrant repair. A review of the literature is presented focusing on anatomy, clinical presentation of ruptured and unruptured aneurysms, noninvasive diagnostic modalities, and techniques for repair of this anomaly.

Transcatheter occlusion of ruptured sinus of valsalva aneurysm: innovative use of available technology

A 9-year-old boy was found to have ruptured sinus of Valsalva aneurysm (RSVA) and aortic coarctation. Following relief of aortic coarctation by balloon angioplasty, transcatheter coil occlusion of the RSVA was performed successfully under transesophageal echocardiographic and fluoroscopic monitoring; bioptome-assisted delivery of 0.052" Gianturco coil was undertaken via a 7 Fr sheath stabilized by an 0.035" guidewire passing through the RSVA and the sheath. This report details the technique of occlusion.

[Multiplane transesophageal echocardiography in the preoperative evaluation of the sinus of Valsalva fistula to right chambers]

INTRODUCTION AND OBJECTIVES

Ruptured sinus of Valsalva aneurysm to right cardiac chambers is an uncommon lesion in Western countries. The prognosis is usually serious unless the condition is promptly treated surgically. For this reason an accurate anatomical and functional evaluation is necessary. The main purpose of this report is to compare the usefulness of multiplane transesophageal echocardiography with transthoracic echocardiography and angiocardiography in the preoperative evaluation of ruptured sinus of Valsalva aneurysm to right chambers.

PATIENTS AND METHOD

Since January 1990, 9 patients (mean age 36,3 18 yr, 6 males) with ruptured sinus of Valsalva aneurysm to right chambers were studied. The pathogenesis was congenital aneurysm in 6 patients, aortic prosthesis endocarditis in one and two cases of iatrogenia: during a percutaneous mitral valvuloplasty and after cardiac surgery. Transthoracic echocardiography was performed in all cases, transesophageal echocardiography in 7 and angiocardiography in 8. Two patients died before surgery, and 7 were successfully operated on.

RESULTS

Transesophageal echocardiography was more useful when compared to transthoracic echocardiography and angiocardiography in detecting: a) the fistula; b) the sinus involved; c) the right chamber affected; d) congenital aneurysms morphology and size; e) aneurysm prolapse through a ventricular septal defect, y f) the identification of other cardiac congenital or acquired anomalies.

CONCLUSIONS

Multiplane TEE is the most accurate tool in the preoperative evaluation of ruptured sinus of Valsalva aneurysm to right chambers.

Sinus of Valsalva aneurysms: 20 years' experience

BACKGROUND

Aneurysms of sinus of Valsalva are rare. Here, we analyze retrospectively patients operated on at our center during the last 20 years.

PATIENTS AND METHODS

One hundred four cases of congential aneurysm of sinus of Valsalva were operated upon between January 1977 and April 1996. Only 12 aneurysms were unruptured. The majority (76.9%) arose from the right coronary sinus. The right ventricle was the most common chamber of rupture (58.6%). Ventricular septal defect was associated in 46 patients (44.2%), of which 28 (60.9%) were supracristal. Ventricular septal defect was more common in aneurysms arising from the right coronary sinus (91.3%). Aortic incompetence was found in 45 patients (43.3%). The defect was closed through the aortic root alone in 24 patients (23.1%) and through both the aortic root and the chamber of rupture in the remaining 80 patients. Six patients underwent aortic valve repair, and 21 an aortic valve replacement.

RESULTS

There were two hospital deaths (1.92%). Morbidities were few. Follow-up ranged from 1 to 20 years (mean 8.2 +/- 1.1). There was one late noncardiac death, and in the majority, the long-term follow-up was uneventful.

CONCLUSION

Surgery for aneurysm of sinus of Valsalva yields gratifying results, and it should be undertaken as soon as the condition is diagnosed.

Doppler echocardiographic characteristics of sinus of valsalva aneurysms

This study evaluated the efficacy of a comprehensive transthoracic Doppler echocardiographic examination for correct detection of SVA and its associated lesions of VSD and aortic insufficiency. A consecutive series of 36 patients was obtained; all had surgical confirmation of the anatomic defects. The location of the SVA was correctly determined in 97% of patients, and the associated presence of a VSD was correctly determined in 79% of the studies. In the cases in which Doppler was available, all 11 patients with associated aortic insufficiency were detected. In this series 32 patients had right SVA, 3 had noncoronary sinus SVA, and 1 had a left SVA. Relative frequency of the rupture site location corresponded closely to that in previous necropsy studies. It is concluded that transthoracic Doppler echocardiography can correctly localize SVAs and most associated lesions.

Echocardiographic diagnosis of aneurysm of the sinus of Valsalva

Echocardiographic and Doppler data of 62 patients with ASOV are presented. Catheterization and angiography were performed in 38 cases and surgery in 25 of the 38. The origin of these aneurysms was the RCS in 56 cases, NCS in 5, and LCS in 1 case. Seven had unruptured aneurysms, 6 rising from RCS dissected into the ventricular septum, producing heart block in 4, AR in 5, mitral regurgitation in 1; 1 aneurysm rising from the LCS was asymptomatic. In other cases (n = 55) the aneurysm had ruptured into one of the cardiac chambers. Thirty-two of the 50 RCS aneurysms ruptured into the RVOT, 13 into the RV cavity, 2 into the RA, and 3 into the LV. Of the 5 NCS aneurysms, (3 ruptured into the RA, 1 into the RV, and 1 into both the RA and RV. Associated VSD was identified in 16 (25.8%) of 62 cases. All of these patients had RCS aneurysms that ruptured into the RVOT. Echocardiography missed VSD in three cases that at surgery were found to have VSD. AR was found in 34 of 62 cases. Echocardiography picked up discrete subaortic stenosis in two cases but missed subvalvar PS in 2 of the 3 cases. A detailed echocardiographic study (two-dimensional, Doppler, and color flow imaging) is accurate in the diagnosis of ASOV, in the identification of its site of origin and rupture, and in the evaluation of the associated defects; in the vast majority of cases, it can totally supplant the need for angiography.

Ruptured Sinus of Valsalva Detected by Biplane Transesophageal Echocardiography

This case illustrates the importance of biplane transesophageal echocardiography and color flow Doppler imaging in detecting a sinus of Valsalva aneurysm and fistula. It also demonstrates how endocarditis can be a complication of this condition.

Transesophageal color flow Doppler features of aorta to right ventricle fistula

A patient developed aortic-to-right ventricular fistula after aortic valve replacement surgery and infective endocarditis. The fistula was not detected by transthoracic two-dimensional echocardiography and color flow Doppler. The transesophageal study, however, was instrumental in diagnosing this entity and prompting surgical resection of the fistula.

Aortoatrial fistulae diagnosed by transthoracic and transesophageal echocardiography: advantages of the transesophageal approach

Aortoatrial fistulae are uncommon, providing a difficult diagnostic challenge both in the clinical diagnosis and in the choice of an imaging modality that fully delineates the abnormal anatomy and flow patterns. This report describes four cases of aortoatrial fistula resulting from three different underlying causes. The fistula communicated with the right atrium in three cases and the left atrium in one. We also describe the diagnostic information obtained during both transthoracic and transesophageal echocardiography and stress that full detail of the abnormal anatomy and shunting could be obtained only with the transesophageal approach, with its improved image quality of the aortic root. No extra information, other than the coronary anatomy, was obtained during aortography in the two patients who underwent cardiac catheterization. Transesophageal echocardiography should, therefore, be the investigation of choice in patients in whom there is a suspicion of aortoatrial shunting after clinical examination and routine transthoracic studies, and it may avoid the need for invasive investigation in these potentially hemodynamically unstable patients.

Transesophageal echocardiography in adults with a continuous precordial murmur

In order to assess the ability of echocardiography in the detection of intracardiac and extracardiac shunts, we studied 11 patients (aged 22-64 yr) with a continuous precordial murmur using transthoracic and transesophageal echocardiography, and correlated the results with the subsequent angiographic and surgical findings. We found that only in 5 of 6 patients with a patent arterial duct could the continuous flow pattern be detected in pulmonary artery using transthoracic echocardiography, whereas it could be readily and accurately identified by transesophageal echocardiography in all patients. The diameters of the patent arterial duct were also measured and found to be in good correlation with subsequent surgical findings (r = 0.98, p less than 0.05). In 2 patients with a ruptured aneurysm of sinus of Valsalva which originated from the right coronary sinus and perforated into the right ventricle, transesophageal echocardiography gave a better image than transthoracic echocardiography. In 2 patients with coronary artery fistula, the origin and site of drainage of the coronary artery could be imaged using transesophageal echocardiography, but the course of coronary artery fistula was more easily detected by transthoracic echocardiography. In one patient with aortopulmonary window, the defect between ascending aorta and main pulmonary artery could readily be imaged by transesophageal echocardiography. We therefore recommend transesophageal echocardiography when evaluating patients with precordial continuous murmur in whom intracardiac and extracardiac shunts or defects are suspected.

Unruptured noncoronary sinus of Valsalva aneurysm: preoperative characterization by transesophageal echocardiography

We describe a patient with a large unruptured sinus of Valsalva aneurysm that was discovered incidentally. Transesophageal echocardiography was used to characterize the aneurysm preoperatively, and was helpful intraoperatively in assessment of the degree of native aortic valvular regurgitation after repair. The use of transthoracic echocardiography, contrast echocardiography, Doppler echocardiography, and transesophageal echocardiography are discussed in this condition.

Echocardiographic diagnosis of a ruptured aneurysm of the sinus of Valsalva: operation without catheterisation in seven patients

A ruptured aneurysm of the sinus of Valsalva was diagnosed by Doppler, colour, and cross sectional echocardiography in a consecutive series of seven patients. The diagnoses were confirmed at operation without cardiac catheterisation. Examination by pulsed and continuous Doppler echocardiography showed continuous turbulence in six patients with aneurysms rupturing into the right ventricular outflow tract and in the patient with rupture of an aneurysm of the non-coronary sinus into the right atrium. Colour Doppler echocardiography showed turbulent flow across the defects in all seven patients. A ventricular septal defect with aortic regurgitation was detected in one patient and an associated ventricular septal defect in another. Doppler, colour, and cross sectional echocardiography were useful non-invasive techniques for diagnosing a ruptured aneurysm of the sinus of Valsalva without the need for cardiac catheterisation.

Diagnosis of ruptured sinus of Valsalva aneurysms: potential value of transesophageal echocardiography

Two patient cases are reported in which an aneurysm of the right coronary sinus of Valsalva ruptured into the right ventricular outflow tract, near the crux of the heart. Transthoracic two-dimensional echocardiography and transesophageal echocardiography using Doppler color flow mapping allowed accurate preoperative assessment of the left-to-right shunt, which was subsequently confirmed by contrast aortography and surgery.

Doppler and two-dimensional echocardiographic features of sinus of Valsalva aneurysm

Doppler, contrast, and two-dimensional echocardiograms of 12 aneurysms of the sinus of Valsalva in 10 consecutive patients were analyzed in order to highlight the diagnostic features. The diagnosis were confirmed by surgical and/or catheterization findings. The aneurysms had ruptured in 7 of 12 (58%). Two-dimensional echocardiography prior to the contrast studies was able to delineate the aneurysms in 7 of 12 (58%). The contrast studies outlined two additional aneurysms. The right aneurysms directed anteriorly and caudally. The noncoronary aneurysms formed an extraneous lumen at the posterior part of the aortic root, mimicking aortic dissection. Doppler examinations showed systolic and diastolic turbulence in five of six (83%) of the right aneurysms rupturing into the right ventricular outflow tract. Color Doppler echocardiography showed a left ventricular diastolic turbulence emanating from the aneurysm in a case with a noncoronary aneurysm rupturing into the left ventricle. It is concluded that the principal Doppler, contrast, and two-dimensional echocardiographic features usually allow a rapid correct diagnosis of sinus of Valsalva aneurysm.

Non-invasive diagnosis of ruptured sinus of Valsalva aneurysm by pulsed Doppler echocardiography

Six cases of ruptured aneurysm of the sinus of Valsalva into the right ventricle, including two post-operative patients with residual murmurs have been reported. Complete diagnosis, including that of residual and associated defects, was made non-invasively using cross-sectional and pulsed Doppler echocardiographic studies. The exact site of rupture was localized by a continuous flow signal in the right ventricle. The diagnosis was subsequently confirmed by cardiac catheterization and angiocardiography in each case.

Echocardiographic diagnosis of multiple congenital aneurysms of the sinus of Valsalva

Aortic regurgitation developed in a 56 year old man with severe nephrotic syndrome. Cross sectional echocardiography showed bilateral aneurysms of the sinus of Valsalva and a bicuspid aortic valve. He died of intercurrent pneumonia. Postmortem examination confirmed the presence of the congenital aneurysms.

Doppler echocardiographic detection of a ruptured acquired aneurysm of the sinus of Valsalva. Clinical-morphologic correlations

Two-dimensional, pulsed Doppler echocardiographic and pathologic features of an unusual form of ruptured aneurysm of the sinus of Valsalva are presented. The presence of an aneurysm of the left sinus of Valsalva protruding into the left atrium complicating acute aortic valvular endocarditis was detected by two-dimensional echocardiography. Rupture of the aneurysm of the sinus of Valsalva into the left atrial cavity was suggested by pulsed Doppler echocardiography. The size and location of the site of the rupture precluded recognition by two-dimensional echocardiography or contrast angiography. This report illustrates the unique value of pulsed Doppler echocardiography to define the location and direction of intracardiac flow patterns in evaluating patients with an aneurysm of the sinus of Valsalva and suspected rupture.

Two-dimensional and Doppler echocardiographic diagnosis of an aortic to right atrial fistula complicating aortic dissection

A 60 year old woman presented with massive aortic root dilation and sudden cardiovascular collapse 10 years after aortic valve replacement. An aortic to right atrial fistula was diagnosed by echocardiographic imaging and Doppler ultrasound. At operation, the patient was found to have chronic aortic dissection with aneurysm formation. Rupture of the aneurysm into the right atrium was confirmed.

Cross-sectional echocardiography in the evaluation of aortic valve prolapse associated with ventricular septal defect

Twenty consecutive patients with ventricular septal defect and aortic valve prolapse were evaluated by cross-sectional echocardiography. Angiographic confirmation was available in all and surgical confirmation was found in 17. In 19, the right coronary cusp was involved and appeared to plug the defect in the precordial long- and short-axis cut. The cusp was deformed and appeared to pivot from the crest of the interventricular septum. In all 19 angiography demonstrated prolapse of the right cusp. Noncoronary cusp prolapse was observed in two by cross-sectional echocardiography and in six by angiocardiography. The ventricular septal defect was perimembranous in 14 and doubly committed subarterial in six by echocardiography. Angiographically, the ventricular septal defect was felt to be perimembranous in 15 and doubly committed in five. Aortic regurgitation was detected by Doppler interrogation in seven, all of whom underwent plication of the right coronary cusp. Angiographic evidence of regurgitation was noted in 11, but four were mild and possibly related to catheter position. Five patients had associated muscular right ventricular outflow tract obstruction and three had a subaortic ridge. Combined cross-sectional and pulsed Doppler echocardiography provide a reliable assessment of right coronary cusp prolapse associated with a ventricular septal defect. Noncoronary cusp prolapse appears more difficult to detect. This technique should help optimize the management of patients by providing a means of early detection prior to the development of aortic regurgitation.

Hemodynamic compromise (tricuspid stenosis and insufficiency) caused by an unruptured aneurysm of the sinus of Valsalva

A patient is described with an unruptured aneurysm of the noncoronary sinus of Valsalva that occupied the right ventricular inflow tract and caused dynamic tricuspid stenosis and insufficiency. Results of two-dimensional echocardiography delineated the anatomy of the aneurysm and pulsed Doppler examination provided evidence that the aneurysm was unruptured. The unruptured aneurysm was resected successfully.