A 45-year-old male presented with progressive dyspnea and bilateral leg swelling, which persisted since a week. Six months earlier, the patient underwent pacemaker implantation after experiencing syncope induced by a complete atrioventricular block. Initially, transthoracic echocardiography (TTE) revealed a large sac-like right sinus Valsalva aneurysm (SVA) dissecting into the interventricular septum (IVS) (Fig. 1, Panel a). We observed blood gushing into the aneurysm because of severe aortic regurgitation, which caused the aneurysm to bulge and extrude into the left ventricular outflow tract during diastole (Fig. 1, Panel b, Video 1). Furthermore, we simultaneously documented systolic and diastolic mitral regurgitation (Fig. 1, Panel c). However, we did not detect any shunt flow between the aneurysm and any chamber. Subsequent magnetic resonance imaging (Fig. 1, Panel d) scans confirmed these initial observations. Another TTE exam revealed a moderate amount of pericardial effusion, SVA enlargement, and left ventricular dilation with impaired biventricular function (aneurysm area increased from 5.1 cm2 to 7.0 cm2 and LV dilation increased from 5 cm to 6 cm) (Fig. 1, Panel e). Therefore, emergency surgery was performed. Intraoperatively, there was a dilation in right SVA with a cavity that led to the dissected IVS. Panels F, G, and H show intraoperative 3D transesophageal echocardiography findings of aneurysm inlets (Fig. 1, Panels f, g, and h, Video 2). The patient received aortic valve replacement and underwent Dacron patching. Follow-up TTE revealed improved biventricular function (Video 3).
Figure 1.
Long-axis transthoracic echocardiography (TTE) image showing the aneurysm bulging into the left ventricle dissecting into the interventricular septum (thin arrow) (a). Blood gushing into the aneurysm because of severe aortic regurgitation during diastole (b). Systole and diastole mitral regurgitation was observed using TTE color m-mode (c). Large sinus Valsalva aneurysm revealed by cardiac magnetic resonance imaging (*) as in TTE (d). Long-axis transthoracic echocardiography (TTE) image (taken during the second TTE examination) showing moderate pericardial effusion and a markedly dilated LV chamber size (e). Intraoperative 3D transesophageal echocardiography (TEE) image showing the aneurysm inlet (black arrow) and diastolic flow filling up the inlet (f). A 3D TEE image reveals that the sinus Valsalva aneurysm (SVA) originated from the right coronary sinus (*) (g). Intraoperative view of the SVA inlet (*) (h)
Video 1
Long-axis transthoracic echocardiography video clip showing a large sinus Valsalva aneurysm and severe aortic regurgitation into the aneurysm.
Video 2
A 3D transesophageal echocardiography video clip showing blood gushing into the aneurysm because of severe aortic regurgitation as well as moderate mitral regurgitation.
Video 3
Video clip of follow-up echocardiography confirming improvement in biventricular function. Note that in this video clip, the mechanical prosthetic aortic valve shows normal function.
Footnotes
Informed consent: Informed consent was obtained from the patient.
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