Case Reports

Three Anomalies and a Complication: Ruptured Noncoronary Sinus of Valsalva Aneurysm, Atrial Septal Aneurysm, and Patent Foramen Ovale

The confluence of atrial septal aneurysm and patent foramen ovale in noncoronary sinus of Valsalva has not been previously documented in the literature.

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A 53 year-old white male with a past medical history of hypertension, hyperlipidemia, and former tobacco use was referred to the Dayton VAMC in Ohio for symptoms that included shortness of breath and a recent abnormal stress test. The patient reported no history of known coronary artery disease (CAD), congestive heart failure, or other cardiovascular diseases. The patient also reported no recent fever, bacterial blood infection, syphilis infection, recreational drug use, or chest trauma.

A physical examination was remarkable for grade 3/6 continuous murmur at the 5th interspace to the left of the sternum and a loud “pistol shot” sound heard over the femoral artery. The patient had jugular venous distension and 2+ leg edema bilaterally. His vital signs were normal, and laboratory blood tests showed normal hemoglobin level and kidney function.

An electrocardiogram showed nonspecific ST segment changes and a transthoracic echocardiogram (TTE) revealed a high-velocity jet in the right atrium (RA) above the tricuspid valve concerning for sinus of Valsalva aneurysm (SVA).

A transesophageal echocardiogram (TEE) showed a “windsock” appearance of the noncoronary SVA with possible rupture into the RA (Figure 1) and atrial septal aneurysm (ASA) with more than 2-cm displacement beyond the plane of the atrial septum and a 2-mm patent foramen ovale (PFO) (Figure 2).

Right heart catheterization revealed elevated RA pressures with positive shunt study showing oxygen saturation step-up in the RA (Figure 3). Left heart hemodynamic measurement from an aortic approach to the distal part of the noncoronary cusp SVA revealed an RA pressure-tracing pattern consistent with rupture of the noncoronary SVA into the RA (Figure 4).

Coronary angiography revealed single vessel CAD involving the proximal right coronary artery.

The primary diagnosis was of acute heart failure secondary to ruptured aneurysm of the noncoronary SVA into RA. The patient also received a secondary diagnosis of atrial septal aneurysm and PFO.

Treatment & Outcome

The patient was treated with aggressive diuresis and responded well to therapy. Considering the high mortality rate associated with a ruptured SVA, the patient was referred to a tertiary care center for surgical evaluation. He underwent repair of aorto-right atrial communication with a Cormatrix patch (Roswell, GA) from the aortic side and with primary closure from the right atrial side with resection of the windsock tract; coronary artery bypass graft x1 with right internal mammary artery to the right coronary artery; closure of the PFO with the Cormatrix patch.

The postoperative TEE confirmed preserved LV and RV function, no shunts, no aortic or tricuspid insufficiency. Biopsy of the tissue resected showed intimal fibroplasia. A TTE completed 1 year after surgery showed normal valvular function and without any structural abnormalities. The patient had improvement in symptoms and an uneventful year after surgical intervention followed by 24 session of cardiac rehabilitation.

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