Aneurysm of sinus of Valsalva: uncommon presentation

AbstractA 28-year-old man presented with acute onset of chest pain. Transthoracic echocardiography confirmed an aneurysm ofthe sinus of Valsalva dissecting into the interventricular septum. During the next 12h, the aneurysm enlarged to involvethe entire interventricular septum, and the patient developed features of cardiac tamponade. He underwent successfulsurgical repair.Keywordsaortic aneurysm, cardiac surgical procedures, heart valve prosthesis implantation, echocardiography, sinus of Valsalva Introduction Aneurysms of the sinus of Valsalva (ASV) are uncom-mon, especially those dissecting into the interventricu-lar septum. If this condition remains untreated, there isa risk of expansion and rupture with seriousconsequences. Case Report A 28-year-old man who had been diagnosed elsewherewith ASV, presented with a non-radiating centralcrushing type of chest pain for 10 days, which hadincreased in intensity in the previous 2 days.Examination revealed a pansystolic murmur grade 3/6over the left lower sternal border. An electrocardio-gram showed first-degree heart block.Echocardiography confirmed a large ASV measuring4–2.6cm, arising from the right coronary sinus and bur-rowing into the interventricular septum, involving thebasal and mid interventricular septum (Figure 1), withearly diastolic flow from the aortic root into the sinus(Figure 2). All cardiac chambers and valves werenormal. There was mild pericardial effusion, mostlyposterolateral to the left ventricle, with a small anterioreffusion, and no chamber compression. A few hourslater, a repeat echocardiogram showed no increase inthe effusion and no signs of chamber compression;however, within 12h of admission, the patientdeveloped a pulseless ventricular tachyarrhythmia thatresponded to defibrillation. Since the patient continuedto be unresponsive, decision was made to electively securethe airway and mechanically ventilate. Echocardiographyshowed a significant increase in pericardial effusion, andthere were features of peric ardial tamponade. Surgicalintervention was undertaken due to the impending riskof rupture of the aneurysm. A transesophageal echocar-diogram before cardiopulmonary bypass confirmed thetransthoracic findings and demonstrated the onset ofaortic regurgitation. An autologous pericardial patchwas used to close the mouth of the ASV arising fromthe right coronary sinus. The right coronary cusp wasretracted and had 2 holes in the coapting edge. Theaortic cusps were excised and aortic valve replacementwas carried out with a 21-mm TTK Chitra mechanical