Journal of Medical Implants & Surgery
Open Access

The Sinus of Valsalva aneurysm (SVA) is a comparatively rare disease that is present in 0.09% of general population. According to last studies, it could be both congenital and acquired [1]. SVAs are unstable pathologies and if rupture can cause heart failure or cardiovascular collapse associated with defect sizes and ruptured chamber. So, differential diagnosis is crucial of SVA from other stable pathologies such as congenital fistulas, arterio-venous malformations and ventricular septal defects. We report an example of ruptured SVA which mimics perimembranous ventricular septal defect (VSD).

Case Presentation

A 38-year-old male patient presented to outpatient clinic of another hospital with sudden fainting, sweating and chest pain before coming to our clinic. The patient was hand-worker. He had no history of chronic disease and habitual drug use other than smoking. Transthoracic echocardiography (TTE) was performed at that hospital and he was diagnosed with asymmetrical septal hypertrophy and VSD. Patient was referral to tertiary hospital for further investigation of VSD by transesophageal echocardiography. Four weeks later, he came to our outpatient clinic with the same complaints. On physical examination, heart rate was 86 per minute, blood pressure was 120/70 mmHg and continuous murmur was heard on mid left sternal border. Other physical examination was normal and no stigmata of systemic disease. ECG was showed normal sinus rhythm. Blood chemistry and blood count values were in normal range. No significant abnormality on Chest X-ray. Doppler TTE was performed. A ruptured, thin-walled, bottleneck aneurysm of sinus of Valsalva was throughout to right atrium close to tricuspid valve. Color Doppler echocardiography showed continuous flow throughout to right atrium via ruptured aneurysm (Figures 1A and 1B) TTE also revealed mild left ventricular hypertrophy and normal systolic functions.

Figure 1: Ecocardiogram (A: with contrast, B: without contrast) showing aortic cavity with communication with aorta and right atrium.

Patient was referred to surgery and recommended to avoid from lifting and hard working. Unfortunately he denied the operation.

We reported a case of ruptured SVA throughout to right atrium it was misdiagnosed as a VSD, correct diagnosis done by cautious TTE.

SVA’s may occur all of three sinuses and the most common one is right [2]. Ten years of survival was 94% and 20 years of survival was 88% according to a long-term study. Before rupture this aneurysms can be asymptomatic and go undiagnosed for decades but huge aneurysms lead to compression adjacent tissues such as coronary arteries or right ventricular outflow tract. So, it causes dyspnea, fatigue or angina pectoris. Sometimes SVA diagnosed incidentally by medical imaging which performed for other reasons [3]. If rupture occurs, clinic driven by ruptured chamber properties and rupture sizes. When it ruptures throughout to pericardium sudden death might be occurring due to tamponade. If it ruptures to left ventricle it mimics aortic regurgitation [4]. When it ruptures to right heart chambers as like this case could be leads a progressive heart failure. SVA is a certain indication of surgical intervention due to instable structure, their sizes could be quickly increased or rupture may occur suddenly. This progress might mostly be mortal.

In this case SVA of non-coronary sinus of Valsalva was seen which is second less common of them. It was misdiagnosed as VSD by echocardiography due to opening of SVA too close to tricuspid valve. Color Doppler failed to demonstrate origin of pathology due to interference of aliasing. But, TTE could discriminate the pathology via cautious and gentle manipulations of probe as seen in case. Discrimination of SVA from VSD is crucial because of instability of SVA’s unlike the VSD’s. Else, differential diagnosis should also be made from Gerbode defect which is a left ventricle-right atrium shunt [5].

In conclusion, ruptured SVA is a mortal disease, should be diagnosed as early as possible and differential diagnosis from other stable diseases essential. Cautious application of TTE can help us accurate and differential diagnosis of SVA.