Unruptured aneurysm of the sinus of Valsalva: a potential source of cerebrovascular embolism

Cardioembolic Stroke in Sinus of Valsalva Aneurysm, A Case Report

A case of cardioembolic stroke in a patient with sinus of Valsalva aneurysm. The patient presented with chief complaints of syncope, with slurring of speech and a history of deviation of angle of mouth to the right side, which resolved over one day. Examination revealed no focal neurological deficit. CT Brain revealed a lacunar infarct over the left frontal cortex. Echocardiography showed sinus of Valsalva aneurysm of the non-coronary cusp. Hence a diagnosis of cardioembolic stroke secondary to thrombus present in the sinus of Valsalva of the aneurysm was considered. This is a rare presentation of Sinus of Valsalva as a cardioembolic stroke.

Pitfalls and Pearls of Imaging Non-traumatic Thoracic Aortic Disease

Imaging of the thoracic aorta is a common request in both the acute and outpatient settings, playing a crucial role in diagnosis and treatment planning of aortic disease. The findings of aortic pathology may be obvious or occult on imaging. Recognizing subtle changes is essential and may lead to early detection and prevention of serious morbidity and mortality. Knowledge of the anatomy and understanding the pathophysiology of aortic disease, as well as selecting the appropriate imaging modality and protocol will enable prompt diagnosis and early intervention of aortic pathology. Currently, computed tomography angiography and magnetic resonance angiography of the aorta are the most commonly used imaging modalities to evaluate the aorta. This review focuses on a spectrum of aortic pathology manifestations on computed tomography and magnetic resonance, including atherosclerosis and acute aortic syndromes, highlighting diagnostic challenges and approaches to aid in image interpretation.

The Characteristics and Outcomes of Native Aortic Valve Thrombosis: A Systematic Review

BACKGROUND

There is a lack of knowledge in the current medical literature about native aortic valve thrombosis.

OBJECTIVES

The aim of this systematic review was to summarize the characteristics, presentations, underlying etiologies, and outcomes of native aortic valve thrombosis and to present a meta-analysis of the best available data.

METHODS

The authors performed a literature search, identified published cases of patients with native aortic valve thrombosis, and pooled the data in this meta-analysis. The statistical analysis included calculations of the prevalence of the various presentations, underlying etiologies, aortic cusp involvement, as well as choices of diagnostic testing. They calculated the sensitivities of the various diagnostic testing as well as in-hospital mortality event rates and the univariate ORs of the risk factors for poor outcomes.

RESULTS

The search strategy and screening process yielded 74 cases of native aortic valve thrombosis, which are included in this meta-analysis. The data revealed that the most common presentation was myocardial infarction in 36%, and the most common underlying etiology was hypercoagulable state in 30%. In-hospital clinical deterioration after presentation including recurrent embolism occurred in ∼38%, and in-hospital mortality rate was ∼20%.

CONCLUSIONS

Native aortic valve thrombosis is clinically relevant, especially in patients presenting with embolic events. Awareness about native aortic valve or root thrombosis as well as its underlying etiologies, diagnostic work-up, and management is essential, because this condition can be associated with poor outcomes.

Ruptured Aneurysm of the Sinus of Valsalva Causing Pulmonary Embolism: A Rare Association

Aneurysms of the sinus of Valsalva are rare. Unruptured sinus of Valsalva aneurysm is usually asymptomatic and rarely presents as right ventricular outflow obstruction, myocardial infarction as a result of coronary artery compression, conduction disturbances, or endocarditis. They have only been reported as the presumed source of embolism in six cases. We report a patient with right sinus of Valsalva rupture to the right atrium and embolization of aneurysm contents to the pulmonary vasculature.

Sinus of Valsalva Thrombosis Detected on Computed Tomography after Transcatheter Aortic Valve Replacement

BACKGROUND AND OBJECTIVES

Leaflet thrombosis after transcatheter aortic valve replacement (TAVR) has been reported recently, whereas thrombus formation in sinus of Valsalva has yet to be fully evaluated. This study describes clinical and cardiac computed tomography (CT) findings of patients with sinus of Valsalva thrombosis.

METHODS

Between March 2011 and Aug 2019, 192 patients underwent cardiac CT after TAVR. After a retrospective review of CT images, 9 patients (82 years, male:female=2:7) who had sinus of Valsalva thrombosis identified by cardiac CT were selected for this study. Patient demographics, interval between TAVR and cardiac CT scan, location and CT attenuation of sinus of Valsalva thrombosis, and presence of concurrent leaflet thrombosis were evaluated.

RESULTS

The median interval between TAVR and cardiac CT was 11 days. Sinus of Valsalva thrombosis was frequently detected in the non-coronary sinus (89%, 8/9), and predominantly located in the bottom of the sinus extending upward towards the sinotubular junction. Three patients had concomitant leaflet thrombosis, and 3 patients had subclinical embolic stroke noted on brain magnetic resonance imaging. All patients had been prescribed aspirin and clopidogrel after TAVR for at least 6 months without anticoagulants.

CONCLUSIONS

Cardiac CT after TAVR can detect sinus of Valsalva thrombosis, and attention should be paid to this potential source of subsequent systemic embolization.

Ruptured Sinus of Valsalva Aneurysm and Gerbode Defects: Patient and Procedural Selection: the Key to Optimising Outcomes

PURPOSE OF REVIEW

In this review, we reflect on the historical background, clinical features and imaging techniques used to assess Gerbode defects and sinus of Valsalva aneurysms. We aim to review the evolution of treatment strategies and the progression towards less invasive management for these conditions.

RECENT FINDINGS

While transthoracic echocardiography is often diagnostic, transesophageal echocardiography (2D and 3D) has improved our understanding of these defects and allowed us to more accurately define their anatomy. Cardiac MRI provides improved assessment of the physiological impact of defects by quantifying shunt volume. Transcatheter techniques are currently vying with surgery as the mainstay of treatment. New insights are being discovered regarding diagnostic modalities and treatment pathways. Defining criteria for patient selection for catheter or surgical therapy is essential when deciding on the optimum intervention for the individual patient.

Cross-sectional imaging of sinus of Valsalva aneurysms: lessons learned

Sinus of Valsalva aneurysm, dilatation of one or more of the aortic sinuses, is a rare but important aortic root defect, which can be a cause of some serious cardiac sequels. The purpose of this article is to review the etiopathogenesis, relevant anatomy, clinical manifestations, potential complications, multimodality imaging features, and management of this rare but important entity of sinus of Valsalva.

Trans-aortic endoscopic ventricular thrombectomy in a patient with HIT and concomitant Aortic and ventricular thromboses

Dual aortic and ventricular thrombi are rare following myocardial infraction. We report the case of a 56-year-old man who initially denied primary percutaneous coronary intervention as a result of psychological phobia. Initial pharmacological management by thrombolysis and heparin was followed by multiple arterial thromboses including those of the left ventricle and right iliac artery with a subsequent diagnosis of heparin-induced thrombocytopaenia. Ensuing surgical management revealed the unanticipated finding of an additional aortic sinus thrombosis that was excised. The left ventricular thrombus was removed endoscopically to prevent ventricular incisions. This case emphasizes the technical advantages of video-endoscopic management of intracardiac thrombi and highlights the unexpected nature of multiple thromboses associated with heparin-induced thrombocytopaenia.

Valsalva aneurysm filled with thrombi mimicking a cardiac tumor

A Valsalva aneurysm filled with thrombi can be difficult to diagnose, because it mimics a cardiac tumor. Both cardiac magnetic resonance imaging (MRI) and transesophageal echocardiogram (TEE) were performed on a patient who showed a low-echoic mass located between the atrial septum and the non-coronary sinus. Based on MRI findings allowing tissue characterization and the accurate location of the mass and the TEE findings of an irregular surface of the mass and a partial defect in the edge of the non-coronary sinus, we diagnosed the mass as a thrombosed Valsalva aneurysm that had perforated the inter-atrial septum. The operative findings coincided with the preoperative diagnosis. Both MRI and TEE are useful for diagnosing this condition.

Unruptured sinus of Valsalva aneurysm involving all three sinuses

In contrast to generalized aneurysmal dilatation of the aortic root, discrete sinus of Valsalva aneurysm is an uncommon condition most often affecting the right coronary sinus. We recently treated a patient without the known connective tissue disorder having discrete aneurysms of all three sinuses.

Surgery for ruptured sinus of valsalva aneurysm into right ventricular outflow tract: role of intraoperative 2D and real time 3D transesophageal echocardiography

A major limitation of the 2D echocardiography during surgery for a complex cardiac lesion is its inability to provide an accurate spatial orientation of the structure. The real time 3D transesophageal echocardiography (RT-3D-TEE) technology available in Philips IE 33 ultrasound machine is relatively new to an operation suite. We evaluated its intraoperative utility in a patient, who was operated for repair of a ruptured sinus of Valsalva aneurysm (RSOVA) and closure of a supracristal ventricular septal defect. The VSD and RSOVA were visualized through different virtual windows in a more promising way on intraoperative RT-3D-TEE than on the 2D echocardiography. The acquired images could be virtually cropped and displayed in anatomical views to the operating surgeon for a clear orientation to the anatomy of the lesion. RT-3D-TEE is a potential intraoperative monitoring tool in surgeries for complex cardiac lesions.

[Perioperative management of a ruptured sinus of Valsalva aneurysm]

Congenital sinus of Valsalva aneurysms are extremely rare in Spain. The lesion consists of a defect that allows the aortic media to separate from the annulus fibrosus of the aortic valve, causing it to dilate with arterial pressure. The natural course of the aneurysm involves the risk of complication due to bacterial endocarditis, with conduction blocks or myocardial ischemia. Rupture of the aneurysm, usually into a right chamber, causes a left-right shunt that leads to heart failure and death if untreated. We present the case of a previously asymptomatic 60-year-old woman who presented with a clinical picture that led to a diagnosis of hyperthyroidism, and in whom there occurred a coincident rupture of a congenital sinus of Valsalva aneurysm. We describe the anesthetic procedure and emphasize the importance of intraoperative echocardiography throughout the resection of the aneurysm.

Aneurysm of the sinus of valsalva

Aneurysms of the sinus of Valsalva (ASVs) are rare. They can be congenital or acquired through infection, trauma, or degenerative diseases. They frequently co-occur with ventricular septal defects, aortic valve dysfunction, or other cardiac abnormalities. Although unruptured ASVs are usually asymptomatic, ruptured ASVs often cause symptoms similar to those of heart failure and produce a continuous, mechanical-sounding murmur. Transsternal or transesophageal echocardiography is usually effective in detecting ASVs. Because symptomatic ASVs pose significant risks for the patient, and because the repair of asymptomatic ASVs generally produces excellent outcomes, surgery is indicated in most cases. The primary goals of surgical repair are to close the ASV securely, remove or obliterate the aneurysmal sac, and repair any associated defects. Operative mortality is generally low except in patients with concomitant bacterial endocarditis or other infections. Late events are uncommon and tend to be related to aortic valve prothesis or Marfan syndrome.

Sinus of Valsalva thrombosis causing renal infarction

A 72-year-old man was admitted to our hospital with a renal infarction. On admission, computed tomography (CT) of the abdomen revealed total occlusion of the right renal artery, which was found to be recanalized with residual thrombus 7 days later. Transesophageal echocardiography and chest CT demonstrated crescent-shaped thrombus in the non-coronary sinus of Valsalva without evidence of aneurysm. After coumadin treatment the patient did not experience recurrent episodes of systemic embolization. Five months after the initiation of anticoagulation, transesophageal echocardiography and chest CT demonstrated disappearance of the thrombus. This is a rare case of renal infarction caused by a thrombus in the non-coronary sinus of Valsalva without aneurysm.

Acute myocardial infarction caused by embolism of thrombus in the right coronary sinus of valsalva: a case report and review of the literature

A 56-year-old man presented with sustained chest pain. Coronary angiography revealed total occlusion of the distal right coronary artery and left anterior descending branch. Left ventriculography depicted a mobile mass in the right sinus of Valsalva originating from the ostium of the right coronary artery. Transesophageal echocardiography (TEE) showed a mobile mass in the sinus of Valsalva and another mobile mass in the aortic arch. The mass at the right sinus of Valsalva was surgically resected, and histologic examination revealed an organized thrombus. Coagulation study showed protein S deficiency. This is the first case of acute myocardial infarction as a result of multiple coronary embolism caused by thrombosis in the right sinus of Valsalva with a second aortic arch thrombosis, contributed by protein S deficiency.

Unruptured congenital aneurysm of the left sinus of Valsalva in an adult with complex left heart malformations

A 26 year old man who presented with the first signs of right heart failure was found to have a large congenital aneurysm of the aortic sinus of Valsalva and of the left coronary sinus. These were combined with left heart anomalies in the form of a bicuspid aortic valve, a rare variant of a persistent left superior vena cava with blood flow from the left atrium through the brachiocephalic vein into the superior vena cava and a kink in the aortic arch. An aortic coarctation had been corrected with a patch 12 years earlier. Although the aneurysm was not perforated and there were no clinical signs of infarction, the aneurysm was resected prophylactically and the left coronary artery was reinserted through a bypass with a Gore-Tex conduit. The case is noteworthy because this diagnosis is very rare and its early treatment may prevent several complications. The clinical features, treatment, and outcome are discussed.

Huge calcified aneurysm of the sinus of Valsalva

Aneurysms of the sinus of Valsalva often remain undiagnosed until they rupture. A 61-year-old man had a huge, heavily calcified unruptured aneurysm, originating from the right sinus of Valsalva, detected incidentally on a chest radiograph taken for the diagnosis of cardiomegaly. Two-dimensional echocardiography revealed pericardial effusion with a huge calcified mass compressing the right ventricular outflow tract. The Doppler color-flow echocardiogram showed blood flow from the aortic root into the aneurysm. A chest computed tomographic scan revealed a large thrombosed aneurysm originating from the aortic root and measuring 10x10 cm. After pericardiocentesis, cardiac catheterization was performed, which showed that the right ventricular systolic pressure had elevated to 80 mmHg. Aortic root aortography demonstrated a huge unruptured calcified aneurysm in the sinus of Valsalva arising from the right coronary sinus. The patient underwent surgical correction to prevent aneurysmal rupture and to relieve the right ventricular outflow obstruction.

Anginal syndrome due to giant unruptured sinus of Valsalva aneurysm

This paper presents a rare cause of angina pectoris in a 43-year-old woman. Her evaluation revealed a compressed and proximally occluded right coronary artery by a giant, unruptured, right sinus of Valsalva aneurysm. The aneurysm was surgically resected and the sinus was successfully reconstructed. On follow-up the patient is asymptomatic.

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.

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.

Asymptomatic murmurs

Images

Spontaneous echocardiographic contrast within an unruptured sinus of Valsalva aneurysm: a potential embolic source diagnosed by transesophageal echocardiography

A 75-year-old male patient had an unexplained transient ischemic attack. Transesophageal echocardiography revealed a large, unruptured Sinus of Valsalva aneurysm which contained spontaneous echo contrast. This finding represents a potential source of embolism.

Thrombus in a normal sinus of Valsalva: angiographic, multiplane transoesophageal echocardiographic, and surgical findings

A large intraluminal thrombus within an otherwise normal sinus of Valsalva was diagnosed in a 41 year old man who was investigated for myocardial infarction. The thrombus was suspected by aortic root injection, confirmed by transoesophageal echocardiography, and treated surgically.

Aneurysm of the left sinus of Valsalva. An unusual source of cerebral embolism

BACKGROUND

Aneurysm of the ascending aorta is rarely reported as the source of emboli. We report a patient with a minor stroke in whom a saccular aneurysm of the left sinus of Valsalva was diagnosed as the presumed source of cerebral embolism.

CASE DESCRIPTION

A 49-year-old right-handed woman presented 10 days after sudden onset of right-sided hemiparesis. Her history was uneventful apart from an acute inflammation of the subcutaneous tissue in the right leg 20 years earlier. A diastolic murmur was heard best over the third left intercostal space. Results of duplex ultrasound investigation of the cerebral vessels, chest x-ray, and electrocardiography and biochemical and hematological variables were normal. CT of the brain showed a small hypodense area in the left frontal region. Transthoracic and transesophageal echocardiography detected moderate aortic regurgitation and a saccular aneurysm originating from the left sinus of Valsalva. The aneurysm had calcified walls and contained thrombotic material. Surgical closure of the aneurysm with a pericardial patch was performed to prevent recurrent embolism and rupture. Coaptation of the aortic valves was achieved, and no residual aortic regurgitation could be detected.

CONCLUSIONS

We conclude that an unruptured sinus of Valsalva aneurysm should be included in the list of sources of embolism. Transthoracic echocardiography establishes the diagnosis. Transesophageal echocardiography provides additional information about the origin and size of the aneurysm and presence of thrombotic material. Surgical closure of the aneurysm prevents rupture and recurrent embolism and possibly corrects aortic regurgitation.

Unruptured congenital aneurysm of the right sinus of Valsalva. Dissecting into the interventricular septum

We report the case of a congenital aneurysm of the right sinus of Valsalva dissecting into the interventricular septum in a 21-year-old man. This condition was diagnosed by echocardiography and magnetic resonance imaging. In particular, transthoracic and transesophageal color-coded Doppler echocardiography showed that there was no communication between the aneurysm and the surrounding heart chambers. The findings were confirmed by angiography. Heart enlargement and other symptoms and signs of heart failure indicated surgical repair of the lesion. Early postoperative dehiscence of the sutured orifice was accurately diagnosed with Doppler echocardiography and angiography. Reintervention was successful in filling and sealing the septal cavity. This case confirms the reported difficulties in the surgical correction of aneurysms of sinus of Valsalva lying within the interventricular septum.

Unruptured aneurysm of the left sinus of Valsalva presenting with atrial fibrillation

Congenital aneurysms arising from the left sinus of Valsalva are extremely uncommon, and when unruptured often asymptomatic. Abnormalities of rhythm are more commonly associated with dilatation of the right coronary sinus although the reason for this is unclear. We report the first case of an unruptured aneurysm involving the left sinus of Valsalva presenting with paroxysmal atrial fibrillation. Two-dimensional echocardiography confirmed the diagnosis.

Acute pulmonary oedema: an unusual clinical presentation of unruptured sinus of Valsalva

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Differences in autonomic nerve function in patients with silent and symptomatic myocardial ischaemia

BACKGROUND

Autonomic neuropathy provides a mechanism for the absence of symptoms in silent myocardial ischaemia, but characterisation of the type of neuropathy is lacking.

AIM

To characterise and compare autonomic nerve function in patients with silent and symptomatic myocardial ischaemia.

METHODS AND RESULTS

The Valsalva manoeuvre, heart rate variation (HRV) in response to deep breathing and standing, lower body negative pressure, isometric handgrip, and the cold pressor test were performed by patients with silent (n = 25) and symptomatic (n = 25) ambulatory ischaemia and by controls (n = 21). No difference in parasympathetic efferent function between patients with silent and symptomatic ischaemia was recorded, but both had significantly less HRV in response to standing than the controls (p < 0.005 for silent and p < 0.01 for symptomatic). Patients with silent ischaemia showed an increased propensity for peripheral vasodilatation compared with symptomatic patients (p < 0.02) and controls (p < 0.04). Impaired sympathetic function was found in patients with pure silent ischaemia (n = 4) compared with the remaining patients with silent ischaemia whose pain pathways were presumed to be intact.

CONCLUSIONS

Patients with silent ischaemia and pain pathways presumed to be intact have an enhanced peripheral vasodilator response, and if this applied to the coronary vasculature it could provide a mechanism for limiting ischaemia to below the pain threshold. Patients with pure silent ischaemia have evidence of sympathetic autonomic dysfunction.