A 19-year-old college athlete presented with dyspnea and was found to have left sinus of Valsalva rupture into the right atrium on a transesophageal…
Key Words: computed tomography, coronary angiography, shortness of breath
Abbreviations and Acronyms: CT, computed tomography
Abstract
A 19-year-old college athlete presented with dyspnea and was found to have left sinus of Valsalva rupture into the right atrium on a transesophageal echocardiogram that was verified on coronary angiogram and computed tomography heart scan. The patient subsequently underwent surgical resection. (Level of Difficulty: Intermediate.)
Graphical abstract
Case Presentation
A 19-year-old college athlete presented with dyspnea on exertion. She had no previous medical history except childhood asthma. Physical examination was unremarkable along with a normal 12-lead electrocardiogram. An echocardiogram revealed normal biventricular function and valvular anatomy; however, an abnormal diastolic flow was noted along the roof of the atrium. A subsequent transesophageal echocardiogram showed a large aneurysmal sac measuring 30 × 25 mm in the right atrium with a direct communication with the left sinus of Valsalva (Video 1). Color M-mode demonstrated continuous flow through the aneurysm into the right atrial cavity (Figure 1). At this point, we considered a differential diagnosis of acute sinus of Valsalva rupture into the right atrium, chronic fistula between sinus of Valsalva and right atrium, and coronary artery fistula.
Online Video 1.
Transesophageal echocardiogram showing a large aneurysmal sac in the right atrium with a direct communication with left sinus of Valsalva.
Figure 1.
Transesophageal Echocardiogram
Transesophageal echocardiogram color M-mode showing continuous flow through the aneurysm into the right atrial cavity. See Video 1.
We then referred the patient for coronary angiography that demonstrated a possible fistula between the left sinus of Valsalva/left main coronary artery into the right atrium (Video 2).
Online Video 2.
Coronary angiogram showing a fistula between left sinus of Valsalva into the right atrium.
Possible surgery was discussed with the patient and a computed tomography (CT) heart scan was obtained pre-operatively. The CT heart scan showed a sinus of Valsalva rupture communicating with the right atrium (Figure 2). Patient subsequently underwent surgical resection. Histopathology of the intra-atrial portion of the aneurysm demonstrated smooth muscle remnants and elastic fragmented tissue leading to a diagnosis of sinus of Valsalva aneurysm rupture.
Figure 2.
CT Heart Reconstruction Image
Computed tomography (CT) heart reconstruction image shows the sinus of Valsalva rupture into an aneurysmal sac in the right atrium. See Video 2.
Left sinus of Valsalva aneurysm rupture into the right atrium is an extremely rare congenital anomaly (1). A multimodality imaging approach is extremely valuable in the management of this condition (2). Treatment for this condition is usually surgical.
Footnotes
The authors have reported that they have no relationships relevant to the contents of this paper to disclose.
Appendix
For supplemental videos, please see the online version of this paper.
References
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