Indian Heart J 2005; 57: 343–345
Manocha et al. Septal Dissection by ASOV Rupture 343 Brief Report
Aneurysm of Sinus of Valsalva Dissecting into Interventricular Septum with Left Ventricular Communication S Manocha, NS Chouhan, S Mittal, AK Omar, Ravi R Kasliwal Department of Non-invasive Cardiology, Escorts Heart Institute and Research Centre, New Delhi
Septal dissection with left ventricular communication is a rare complication of aneurysm of sinus of Valsalva. This report describes a case of aneurysm of sinus of Valsalva with septal dissection, almost in its entirety with left ventricular communication – which is a very rare occurrence. (Indian Heart J 2005; 57: 343–345) Key Words: Sinus of Valsalva aneurysm, Septal dissection, Echocardiography
A
neurysms of sinus of Valsalva (ASOV) are rare and account for only 1% of congenital cardiac anomalies with slightly higher incidence in Asian subcontinent. Septal dissection is an extremely rare complication and left ventricular communication is even rarer and to-date, only eight such cases have been reported.1,2 Case Report
A 33-year-old gentleman with no history of hypertension, diabetes mellitus or rheumatic heart disease presented with history of sudden onset retrosternal chest pain along with dizziness on standing lasting for 15-20 min, 3 days prior to admission. General physical examination revealed tachycardia (pulse rate 106 beats/min) with wide pulse pressure (blood pressure 146/56 mmHg in right arm, in supine posture). The pulse was high volume, normal in character and all peripheral pulses were well palpable. Precordial examination revealed grade III/VI to and fro murmur all over the precordium. Twelve-lead surface electrocardiogram (ECG) and 24-hour Holter monitoring did not reveal any atrioventricular conduction disturbance. Two-dimensional transthoracic and transesophageal echocardiography (TTE and TEE) revealed large aneurysm of sinus of Valsalva of right coronary cusp burrowing into the interventricular septum (IVS) (Fig. 1) causing septal dissection, almost in its entirety with a small perforation
Correspondence: Dr Ravi R Kasliwal, Director, Department of Noninvasive Cardiology, Escorts Heart Institute and Research Centre New Delhi 110025. e-mail: rrkasliwal@hotmail.com
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Fig. 1. 2D echo (Plax view) demonstrating aneurysm of sinus of Valsalva dissecting into septum. The arrow shows the entry point of septal dissection. 2D echo: two-dimensional echocardiography; LA: left atrium; LV: left ventricle; An: aneurysm of sinus of Valsalva
toward apical margin of the septal dissection resulting in a communication with the left ventricular cavity (Figs 2 and 3). There was significant to and fro flow into the sinus of Valsalva aneurysm (Figs 4 and 5). Mild aortic regurgitation was also present. The findings were confirmed intra-operatively. The defect was repaired by Dacron patch closure of mouth of aneurysm and subsequently the cavity became thrombosed (Fig. 6). Post-operatively, the patient had an uneventful recovery and was discharged on post-operative day 8. The patient was asymptomatic on his last follow-up at 30 days.
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Fig. 2. 2D echo (Plax view) demonstrating the left ventricular communication toward apical margin of dissected septum. Ao: aorta; An: aneurysm of sinus of Valsalva; LV: left ventricle, LA: left atrium
Fig. 4. Transesophageal color Doppler (long axis view) showing blood flow from septal dissection to ascending aorta in systole. Ao: aorta; LVOT: left ventricular outflow tract; An: aneurysm
Fig. 3. Transesophagal echo (transgastric short axis view) showing rent in the septum responsible for communication between aneurysm and left ventricle. An: aneurysm of sinus of Valsalva; LV: left ventricle
Fig. 5. Transesophageal color Doppler view is showing blood flow into septal dissection from ascending aorta in diastole. Ao: aorta; LV: left ventricle; LA: left atrium; An: aneurysm of sinus of Valsalva; IVS: interventricular septum; RV: right ventricle
Discussion
ASOV into IVS is exceedingly rare. This rare condition of rupture of ASOV into IVS mostly involves right coronary sinus with further communication into one or both of the ventricles, with significant aortic regurgitation, congestive heart failure and conduction disturbance. In the present case also, ASOV originated from right coronary sinus, dissected into IVS and finally opened into left ventricle through a small perforation in the IVS. To our knowledge, only eight such cases have been so far reported in the literature. However, this is the only case in which transthoracic, transesophageal and post-operative echocardiography images have been demonstrated. Echocardiographic picture in such cases is diagnostic in
Aneurysms of sinus of Valsalva account for only 1% of congenital cardiac anomalies. Out of these aneurysms, 70% arise from right sinus of Valsalva, 25% from noncoronary sinus and only < 5% from the left coronary sinus.1 Most common complications resulting from ASOV include aortic regurgitation, coronary artery flow compromise, atrioventricular conduction blocks, endocarditis and most importantly, rupture into cardiac chambers.2-4 Rupture most commonly occurs into right ventricle (60%-90%) and less commonly into right atrium (10%), left atrium (3%), pericardium and ventricular septum (<1%).5 Rupture of
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may present with a cavity within IVS. However, absence of ASOV and communication of the cavity with it will differentiate these entities from the former one. On the other hand, aorta to left ventricular tunnel presents with a communication between aortic root and left ventricle but in this condition, there is no cavity within IVS. Thus, an accurate diagnosis of ASOV rupture into IVS with left ventricular communication can be made on the basis of TTE and TEE to guide successful surgical repair. References
Fig. 6. 2D echo (Plax view) during post-operative period showing patch repair of aneurysm and thrombosed septum.
most instances. Demonstration of the cavity within IVS, communicating with both aneurysmally dilated sinus of Valsalva as well as left ventricle is virtually pathognomonic of the disease entity. Traumatic dissection of IVS, congenital aneurysm of IVS and necrosis within intra-septal tumor
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1. Wells T, Byrd B, Neirste D, Fleurelus C. Sinus of Valsalva aneurysm with rupture into the interventricular septum and left ventricular cavity. Circulation 1999; 100: 1843–1844 2. Choudhary SK, Bhan A, Reddy SC, Sharma R, Murari V, Airan B, et al. Aneurysm of sinus of Valsalva dissecting into interventricular septum. Ann Thorac Surg 1998; 65: 735–740 3. Choudhary SK, Airan B, Venugopal P. Dissecting aneurysm of the interventricular septum. Eur J Cardiothorac Surg 2003; 23: 650–651 4. Wu Q, Xu J, Shen X, Wang D, Wang S. Surgical treatment of dissecting aneurysm of the interventricular septum. Eur J Cardiothorac Surg 2002; 22: 517–520 5. Prian GW, Dieltrich EB. Sinus of Valsalva abnormalities: a specific differentiation between aneurysm of and aneurysm involving the sinus of Valsalva. Vasc Surg 1973; 7: 155–164
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