Rupture of a sinus Valsalva aneurysm. Report of a case diagnosed preoperatively by echocardiography

A 32-year experience with surgical repair of sinus of valsalva aneurysms

INTRODUCTION

Sinus of Valsalva (SoV) aneurysms are rare (0.15% to 1.5% CPB cases) and five times more frequent in Asians. Usually congenital, SoV aneurysms arise from the right or noncoronary sinus, are associated with other cardiac defects, and are repaired primarily or with a patch. Acquired SoV aneuryms develop secondary to infection or trauma. Here, we describe our 32-year experience with SoV aneurysm repair in a Western population.

METHODS

A retrospective review identified 22 patients who underwent SoV aneurysm repair between 1971 and 2003. Data is presented as mean +/- standard error (median).

RESULTS

Dyspnea was the most common presenting symptom. Nineteen of 22 patients were ruptured at the time of operation; three were found incidentally. Fifteen patients had associated cardiac defects including ventricular septal defect (VSD) (6), aortic insufficiency (6), and coarctation (3). One patient, repaired primarily, required reoperation for recurrence. All other patients underwent patch repair. The operative survival was 95% (21/22). There were five known late deaths at 6.6 +/- 2.3 (5.7) years post-repair. Five and ten year survival rates were 84.9 +/- 11% and 59.4 +/- 17%, respectively.

CONCLUSION

Observed differences in the sinus of origin, age at presentation, associated cardiac malformations, and mortality in our Western series versus previous Asian cohort studies likely reflect a racial disparity and higher prevalence of acquired versus congenital SoV aneurysms. We recommend a thorough search for a VSD in all cases and use of patch repair, regardless of size, to reduce risk of recurrence.

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.

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.

The evaluation of the abdominal aorta: a "how-to" for cardiac sonographers

A thorough evaluation of the abdominal aorta can be readily achieved by use of the standard views of the echocardiographic examination. The ultrasound evaluation of the abdominal aorta represents a logical extension of the standard echocardiographic examination of the adult patient. This article provides the information needed to carry out a complete ultrasound examination of the abdominal aorta including the anatomy, the vascular disease, and the steps involved in accomplishing the ultrasound examination of the abdominal aorta.

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

The aim of this study was to evaluate the role of echocardiography in the diagnosis of sinus of Valsalva aneurysms projecting toward the right heart cavities. Three patients who had a ruptured aneurysm of a sinus of Valsalva diagnosed by echocardiography and confirmed by catheterization underwent cardiac surgery. In two patients, the aneurysm originated from the right coronary sinus and had perforated into either the inflow or outflow tract of the right ventricle. In the third patient, the aneurysm, which originated from the noncoronary sinus, ruptured into the atrium. A fourth patient was also investigated and had an unruptured aneurysm of the right coronary sinus projecting into the right ventricular outflow tract. M-mode, two-dimensional and contrast echocardiographic studies were performed before cardiac catheterization in all patients and after surgery in three patients. M-mode echocardiography was useful only when the aneurysm had an anterior projection, whether or not the aneurysm was ruptured. Conversely, two-dimensional echocardiography was always able to identify the aneurysmal sac which appeared as an abnormal circular thin-walled structure protruding into the right heart cavities. By using multiple views, it was possible to investigate the whole abnormal structure and locate the sinus from which the aneurysm originated. The use of the echo contrast technique allowed more precise definition of the aneurysmal sac and diagnosis of a left to right shunt by demonstrating a negative contrast image in the right cavities. On the other hand, no negative contrast image was recorded in the patient with an unruptured aneurysm or in the two instances of a successful surgically reconstructed aorta.

Ruptured sinus of valsalva aneurysm in children: report of two cases and literature review

Two children with ruptured sinus of Valsalva aneurysm are described, each with a ventricular septal defect, and in one there was also an associated discrete subvalvular aortic stenosis. The diagnostic appearance of two-dimensional echocardiography and axial angiocardiography are emphasized to allow early diagnosis and surgical repair. A literature review of recent reports in English disclosed that 13 patients under age 20 had been reported to have ruptured sinus of Valsalva aneurysm.

Contrast echocardiography

Contrast echocardiography is the technique of injecting an echo-producing, biologically compatible solution into the bloodstream and using M-mode and/or two-dimensional echocardiography to observe intracardiac bloodflow patterns revealed by the resulting cloud of echoes. This information was previously available only from angiocardiography. Contrast echocardiography has become a well-established adjunct to M-mode and two-dimensional echocardiographic examination and is valuable in the identification and validation of normal and abnormal cardiac structures, for the demonstration (and exclusion) of intracardiac as well as extracardiac shunts, and in the diagnosis of valvular regurgitation. In addition many clinical applications are being developed. Future research directions include development of videodensitometric techniques for contrast quantitation, finding contrast agents capable of passing the lung capillary bed and measurement of right heart pressures using microbubble resonance techniques.

Ruptured aneurysm of the right sinus of Valsalva: two pulsed Doppler echocardiographic studies

Pulsed Doppler echocardiography (PDE) was performed on two cases with ruptured aneurysm of the right sinus of Valsalva into the right ventricle. PDE revealed a wide band pattern throughout the cardiac cycle when the sample volume was placed within the aneurysm. In the right ventricle below the aneurysm, a continuous disturbed flow in case 1 and a diastolic turbulence in case 2, was widely recorded, respectively. In contrast, the flow pattern of the right ventricular outflow tract distal to the aneurysm showed a systolic disturbed flow in both cases. These PDE findings were consistent with the shunt flows in angiocardiography.

Echocardiographic diagnosis of congenital sinus of Valsalva aneurysm with dissection of the interventricular septum

A case is reported in which a congenital aneurysm of the right coronary sinus of Valsalva ruptured and dissected into the interventricular septum. M-mode and cross-sectional echocardiographic examination allowed accurate preoperative assessment of the pathologic anatomy, which was confirmed by angiography, surgery and autopsy. Dissection of the interventricular septum by a congenital sinus of Valsalva aneurysm is a rare lesion, has a poor prognosis, and can be diagnosed noninvasively with echocardiography.

Detection of ruptured aneurysm of sinus of Valsalva by contrast two-dimensional echocardiography

The M-mode and two dimensional echocardiographic features are described of a patient with rupture of a sinus of Valsalva aneurysm into the right atrium. A clear echo-free zone arising from the tip of the aneurysm is visualised in the right atrium in diastole by peripheral injection of echocardiographic contrast material. At surgery a fistula was seen between the non-coronary cusp and the right atrium.

Ruptured sinus of Valsalva aneurysm: diagnosis by echocardiography

Fluttering of the right side of the interventricular septum noted on M-mode echocardiography in association with a bulging of the right sinus of Valsalva detected by two-dimensional echocardiography were present in a patient. These two echocardiographic findings should alert the clinician to a diagnosis of a ruptured sinus of Valsalva aneurysm.

Echocardiographic features of an unruptured aneurysm of the right sinus of Valsalva

A 2-cm aneurysm of the right sinus of Valsalva was documented in a patient with a prosthetic aortic valve. The M-mode findings differed from prior reports and mimicked those of aortic root dissection or a catheter placed in the right ventricular outflow tract. Two-dimensional echocardiograms readily distinguished the aneurysm of the right sinus of Valsalva from the alternative possibilities.

Right sinus of Valsalva-right atrial fistula secondary to nonpenetrating chest trauma: a case report with description of noninvasive diagnostic features

A sinus of Valsalva-right atrial fistula secondary to nonpenetrating chest trauma is described. Echocardiogrpahy demonstrated diastolic fluttering of the anterior tricuspid valve, suggesting a left-to-right shunt at the level of the right atrium. External jugular venous pulse tracings revealed large alpha waves and attenuation of the y descent. Cardiac catheterization disclosed a fistulous communication between the right sinus of Valsalva and right atrium. After surgical repair of the fistula, the ultrasonic recording and external pulse tracing reverted to normal. We believe this is the first description of such a shunt after blunt thoracic trauma.

Echocardiographic features of an aneurysm of the left sinus of Valsalva

The echocardiographic features of an aneurysm of the left sinus of Valsalva are described and correlated with angiographic findings. The echocardiogram showed the presence of a thin line of echoes occurring proximal to the anterior leaflet of the mitral valve and moving in and out of apposition with the posterior aortic wall. During systole, this line of echoes moved away from the aorta into the left atrium, and during diastole, the line moved into the aorta. Recognition of these features provides a potential noninvasive way to diagnose aneurysms of the left sinus of Valsalva prior to rupture.

Echocardiography of the aortic root

The anterior and posterior walls of the aortic root are recognized as a pair of parallel linear signals which move anteriorly in systole and posteriorly in diastole. Valve cusps appear as thin lines which move briskly toward the periphery of the aortic lumen in systole and coapt in the middle in diastole producing a box-like configuration. Cusp calcification results in the appearance of multiple, linear echoes within the aortic root. Mild aortic stenosis is characterized by lightly calcified leaflets whereas heavy calcification, which completely obscures cusp motion, signifies severe stenosis. Aortic aneurysms produce significant enlargement of the aortic root image; marked widening of the aortic walls indicates the presence of aortic root dissection, but there are important limitations and pitfalls in the diagnosis of this condition. A markedly eccentric diastolic cusp position within the aortic lumen resulting in asymmetric images of the leaflets in systole is the hallmark of a bicuspid aortic valve. An abrupt premature closure of the valve leaflets in early systole is typical of subaortic membranous stenosis. In tetralogy of Fallot the aortic root is dilated and overrides the ventricular septum.

Real-time observation of ruptured right sinus of Valsalva aneurysm by high speed ultrasono-cardiotomography. Report of a case

A two-dimensional echocardiographic manifestation of a ruptured right sinus of Valsalva aneurysm is described in this case report. The ultrasono-cardiotomograms demonstrated the aneurysm cut longitudinally and protruding into the outflow tract of the right ventricle. The configuration of the aneurysm was consistent with the contrast medium-filled sinus demonstrated by angiocardiography. In systole, the aneurysmal sinus moved anteroinferiorly together with the aortic wall. The echocardiogram revealed an abnormal two-layered horizontal echo in the right ventricle which showed the aneurysm when the ultrasonic beam passed through the interventricular septum near the aortic root and mitral leaflets. During the operation, the protruding sinus and a small interventricular septal defect in the membranous septum under it were observed through the opened right ventricle. After the closure of the aneurysm, the two-dimensional echocardiogram no longer showed an abnormal configuration.

Echocardiography diagnosis of ruptured aneurysm of sinus of Valsalva. Report of two cases

Echocardiographic features of two cases of ruptured congenital aneurysm of Valsalva sinus with (case1) and without (case 2) a supracristal ventricular defect were studied before and after surgery by standard echocardiography. M-mode scan and two-dimensional echocardiography. Discontinuity was observed in the echo from the aneurysm wall of the Valsalva sinus in case 1 with ruptured aneurysm, but was not observed in a similar case of unruptured aneurysm. Herniation of the right coronary cusp of the aortic valve into the right ventricular outflow tract was also observed in case 1. After surgical correction the echo from the aneurysm wall and from the herniated right coronary cusp of the aortic valve disappeared. Discontinuity in the echo from the anterior aortic wall and the interventricular septum also disappeared. In case 2, discontinuity in the echo from the anterior aortic wall, and tricuspid flutter with an abnormally low early diastolic peak were observed. These abnormalities disappeared after surgery. The ability of echocardiography to detect ruptured Valsalva aneurysm is discussed.