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

Ruptured right Valsalva sinus into the right atrium due to infective endocarditis: a case report

Rupture of Valsalva sinus remains a very rare and deadly complication of Valsalva sinus aneurysm with a high mortality rate. We report here the case of a 47-year-old man who presented to the emergency department with acute exercise-induced dyspnea, chest pain, and fever. Transthoracic (TTE) and transesophageal echocardiography (TEE) highlighted a rupture of the right Valsalva sinus in the right atrium due to infective endocarditis. After stabilization of the patient, a successful surgical repair with double pericardial patches was performed.

Contained Rupture of Sinus of Valsalva Aneurysm in a 64-Year-Old Man

We report a contained rupture of a right coronary sinus of Valsalva aneurysm, in which repair resulted in symptomatic improvement. Patients often present with symptoms secondary to rupture of the sinus of Valsalva aneurysm into one of the cardiac chambers, or secondary to the compression of adjacent structures. Whereas sinus of Valsalva aneurysms and their rupture are well reported in the literature, contained ruptures have been described only rarely. In those cases, symptoms often arose from compression of adjacent structures. Although transesophageal echocardiography is considered to be the diagnostic method of choice, cardiac magnetic resonance imaging and computed tomography can be equally helpful in establishing the diagnosis and delineating the lesion. Diagnosis and prompt repair in our 64-year-old patient resulted in the rapid resolution of his symptoms.

[Large aneurysm of the left sinus of Valsalva in a 54-year-old man successfully treated with surgery]

Sinus of Valsalva aneurysms are very rare and are often asymptomatic. Clinical manifestations depend on associated complications, most commonly rupture or dissection. We describe the case of a 54-year-old male presenting with exercise-related angina and dyspnea and in whom we found a large unruptured aneurysm of the left sinus of Valsalva. On angiography, he also had a severe stenosis of the left artery descending and the diagonal. He underwent a successful surgical intervention with bypass and closure of the aneurysm.

Gigantic unruptured sinus of Valsalva aneurysm presenting as an incidental murmur

We report a case of a 56-year-old man referred by his family physician with an asymptomatic cardiac murmur. Trans-thoracic echocardiography (TTE) suggested an unruptured right sinus of Valsalva aneurysm (SVA) causing extrinsic compression of the right ventricular outflow tract. This was confirmed with an ECG-gated cardiac CT showing a large right SVA measuring 35×37×42 mm in size. Coronary angiography demonstrated non-obstructive coronary artery disease. Ascending thoracic anterior in the right anterior oblique view delineated the right SVA. The patient underwent aortic valve sparing surgical repair of the aneurysm with an excellent result. Echocardiography confirmed obliteration of the aneurysm and normal aortic valve function postoperatively.

An unusual and life-threatening cause of epigastric pain presenting to the general surgical team: a case report

As general surgeons, we are regularly referred patients with epigastric pain. There are a huge number of common pathologies which cause this complaint, most of which are gastrointestinal in origin. Although the old adage goes 'common things are common', we must always keep our minds open to the possibility of the uncommon and not miss warning signs which are present in the history or examination. We present the case of a 59-year-old woman with a ruptured sinus of Valsalva aneurysm presenting to the accident and emergency department as epigastric pain.

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.

Sinus of Valsalva Aneurysm and Ventricular Tachycardia During Pulmonary Artery Catheterization

Pulmonary artery catheterization is associated with numerous complications, including serious arrhythmias. We report a case where ventricular tachycardia occurred repeatedly during attempted pulmonary artery catheterization, precluding successful catheterization. Transesophageal echocardiography was used to image the tricuspid valve and right ventricle and revealed a Sinus of Valsalva aneurysm protruding significantly into the right ventricle and obstructing advancement of the pulmonary artery catheter. Our case reveals another identifiable cause of serious arrhythmia during pulmonary artery catheterization and highlights how transesophageal echocardiography can be useful in unanticipated ways during cardiac anesthesia and surgery.

[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.

Imaging of an aneurysm of the sinus of Valsalva with transesophageal echocardiography, contrast angiography and MRI

A sinus of Valsalva aneurysm is an uncommon congenital defect, which requires appropriate diagnosis with either echocardiography, magnetic resonance imaging or contrast angiography. Treatment consists of aortic valve repair. We describe a young woman with an aneurysm of the non-coronary sinus of Valsalva, an atrial septal defect and pulmonary insufficiency. The different imaging techniques and possibilities of surgical correction are described.

Unruptured congenital aneurysm of the sinus of Valsalva presenting with pulmonary stenosis

Congenital aneurysm of the sinus of Valsalva is a rare cardiovascular anomaly. It is usually silent until rupture occurs. The natural history of unruptured aneurysm of the sinus of Valsalva is still not clear, and the therapeutic strategy is uncertain. Here we reported a case of unruptured aneurysm of the sinus of Valsalva which was correctly diagnosed before invasive diagnostic procedures. A 30-year-old female noted mild palpitation and dyspnea for 1 month. Physically, a grade 3/6 systolic ejection murmur at upper left sternal border was detected. Echocardiography revealed dilatation and irregular protrusion of the right sinus of Valsalva encroaching on right ventricular outflow tract to cause obstruction. With these findings, unruptured aneurysm of the sinus of Valsalva with pulmonary stenosis was diagnosed. Cardiac catheterization and angiography confirmed the diagnosis. The aneurysm was repaired with a Dacron patch with good results. It is concluded that sinus of Valsalva aneurysm can be diagnosed by echocardiography before its rupture so as to render a proper management for this potentially life-threatening anomaly.

Aneurysms in the left ventricular outflow tract: clinical presentation, causes, and echocardiographic features

We present a descriptive compendium of anatomically interrelated aneurysms and aneurysmal-like structures arising in and around the left ventricular outflow tract. Images selected from the Mayo Clinic echocardiography database illustrate classic or typical examples of each entity. Essential morphologic features of each lesion are described. Clinical presentation, causes, and diagnostic echocardiographic features taken together can improve recognition and clinical management of this diverse group of anomalies.

Congenital sinus of Valsalva aneurysm: a multiplane transesophageal echocardiographic experience

Sinus of Valsalva aneurysm is a rare congenital anomaly which, if overlooked, may be associated with increased mortality and morbidity. Multiplane transesophageal echocardiography proved useful in identifying a variety of associated structural heart disease. This study sought to assess the accuracy of the surgical result on the basis of the multiplane transesophageal echocardiography findings and to describe patient demographics and clinical outcome in an Oriental patient cohort. From July 1984 to December 1995, clinical, catheterization, echocardiographic, and surgical results were retrospectively studied in 23 patients with documented sinus of Valsalva aneurysm. Compared with previous reports of Oriental patients, our patient cohort was older (p < 0.025), had more associated aortic, mitral, and tricuspid regurgitation (p < 0.01), but had fewer coexistent ventricular septal defects (p < 0.01), and had more associated coronary artery disease (9%). Multiplane transesophageal echocardiography precisely showed three undiagnosed and/or ambiguous transthoracic echocardiographic studies, and the preoperative transesophageal echocardiography TEE findings were confirmed intraoperatively in the last eight consecutive patients. We concluded that multiplane transesophageal echocardiography provides conclusive information and is the current technique of choice for diagnosis and clinical management of patients with sinus of Valsalva aneurysm; although the natural history of sinus of Valsalva aneurysm remains uncertain, it is likely that the incidence of unruptured sinus of Valsalva aneurysm is considerably higher in the elderly than has been previously reported.

Transesophageal echocardiography

This article presents an overview of the benefits and efficacy of transesophageal echocardiography (TEE) in the critically ill patient. The echocardiographic evaluation of ventricular function both regional and global, is discussed with special emphasis on ischemic heart disease; assessment of preload, interrogation of valvular heart disease (prosthetic and native) and its complications; endocarditis and its complications; intracardiac and extracardiac masses, including pulmonary embolism; aortic diseases (e.g., aneurysan, dissection, and traumatic tears); evaluation of patent foramen ovale and its association with central and peripheral embolic events; advancements in computer technology; and finally, the effect of TEE on critical care.

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.