© 2014, Wiley Periodicals, Inc. DOI: 10.1111/echo.12755
Echocardiography
A Thrombotic Right Sinus of Valsalva Aneurysm Causing Acute Myocardial Infarction and Ischemic Stroke Nihat Polat, M.D., Abdulkadir Yildiz, M.D., Murat Yuksel, M.D., Halit Acet, M.D., and Sait Alan, M.D. Department of Cardiology, Dicle University School of Medicine, Diyarbakir, Turkey
(Echocardiography 2015;32:189–191) Key words: sinus of Valsalva aneurysm, thrombosis, myocardial infarction, stroke
A 71-year-old man with a history of hypertension was referred for primary percutaneous coronary intervention because of acute inferior myocardial infarction. In physical examination there was no neurological deficit, but the cooperation was poor. There was a grade 2/6 systolic ejection murmur over the right parasternal area. As we could not engage to the right coronary ostium, we performed unselective aortic root injection. During this injection, the right Judkins catheter engaged to right coronary artery (RCA) ostium after passing through a thrombus like mass and it showed RCA was occluded at ostium with a thrombus. After manual thrombus aspiration and dilatation with a 2.0 9 15 mm ryujin plus balloon, TIMI 3 flow was achieved and the procedure was completed. Both transthoracic echocardiography (TTE) and thoracic computed tomography (CT) showed a large thrombosed aneurysmatic dilatation of right sinus of Valsalva which caused an obstruction in right ventricular outflow tract with a gradient of 66/34 mmHg (Figs. 1–3, and movie clips S1–S3). There was no acute pathology in cranial CT of the patient which was performed due to the cooperation problem. Follow-up CT at 24th hour revealed multiple cerebral thromboemboli. The patient refused to have a surgical correction of the sinus Valsalva aneurysm and coronary stenosis. The patient discharged on aspirin, clopidogrel and warfarin treatment. Follow-up TTE at 4th week revealed the partial regression of the thrombus (movie clip S4). Address for correspondence and reprint requests: Abdulkadir Yildiz, M.D., Dicle University School of Medicine, Heart Hospital 21280 Sur, Diyarbakir, Turkey. Fax: +90 0412 248 84 40; E-mail: [email protected]
Aneurysm of the sinus of Valsalva (ASV) is defined as the dilatation of one of the three aortic sinuses between the aortic valve annulus, and the sinotubular junction or supra-aortic ridge.1 They can be congenital or acquired. Acquired aneurysms are caused by conditions affecting the aortic wall, such as infections (syphilis, bacterial endocarditis, or tuberculosis), trauma, or connective tissue disorders and usually ASV originates from the right coronary sinus in of patients.1,2 Aneurysms of the sinus of Valsalva are usually diagnosed after an acute rupture into an adjacent cardiac structure.1 Prior to rupture, ASV may present with conduction system abnormalities attributable to erosion into the interventricular septum, thromboembolism originating in the aneurysm sac,1 acute myocardial infarction,3 and right ventricular outflow tract obstruction.4 Embolic events due to unruptured ASV are uncommon. As in this case, large thrombus may occur within the aneurysm and depending on the thrombus variety of embolism may develop. In this case, it should be remembered that angiography catheter maneuvers could result with embolization of the thrombotic material. As the patient had cooperation disorder and acute chest pain at presentation in the present case, we thought that dynamic changes in the characteristics of the thrombus may result in simultaneous coronary and cerebral embolization. To our knowledge this is the first case of ASV thrombosis presented with both acute myocardial infarction and acute stroke, which teaches us thrombosed sinus of Valsalva aneurysms should be kept in mind in patients with acute coronary syndrome in case of accompanying cerebral condition. 189
Polat, et al.
Figure 1. Parasternal long- and short-axis view showing thrombotic right sinus of Valsalva aneurysm. AoV = aortic valve; LA = left atrium; LCC = left coronary cusp; LV = left ventricle; IVS = interventricular septum; NCC = noncoronary cusp; PA = main pulmonary artery; PW = posterior wall; RCC = right coronary cusp and asterisk (*) and arrows, thrombotic right sinus of Valsalva Aneurysm.
Figure 2. Color and continuous-wave Doppler demonstration of the right ventricular outflow tract obstruction. AoV = aortic valve; PA = main pulmonary artery.
Figure 3. A, B. Computed tomographic views demonstrating thrombotic right sinus of Valsalva aneurysm. Ao = ascending thoracic aorta; X = thrombotic right sinus of Valsalva aneurysm.
References 1. Feldman DN, Roman MJ: Aneurysms of the sinuses of Valsalva. Cardiology 2006;106:73–81. 2. Ott D: Aneurysm of the sinus of Valsalva. Semin Thorac Cardiovasc Surg Pediatr Card Surg Annu 2006;9:165– 176. 3. LaPorte F, Selton SC, Bonnemains L, et al: Acute myocardial infarction caused by sinus of Valsalva aneurysm. Echocardiography 2011;28:E19–E20. 4. Avci A, Akcakoyun M, Alizada E, et al: Severe right ventricular outflow obstruction by right sinus of valsalva aneurysm. Echocardiography 2010;27:341–343.
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Supporting Information Additional Supporting Information may be found in the online version of this article: Movie clip S1. Parasternal long-axis view showing thrombotic right sinus of Valsalva aneurysm. Movie clip S2. Parasternal short-axis view showing thrombotic right sinus of Valsalva aneurysm.
Thrombotic ASV causing Coronary and Cerebral event
Movie clip S3. Color Doppler demonstration of the right ventricular outflow tract obstruction.
Movie clip S4. Follow-up transthoracic echocardiogram at 4th week showing partial regression of the thrombus in parasternal long-axis view.
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Echocardiography
A Thrombotic Right Sinus of Valsalva Aneurysm Causing Acute Myocardial Infarction and Ischemic Stroke Nihat Polat, M.D., Abdulkadir Yildiz, M.D., Murat Yuksel, M.D., Halit Acet, M.D., and Sait Alan, M.D. Department of Cardiology, Dicle University School of Medicine, Diyarbakir, Turkey
(Echocardiography 2015;32:189–191) Key words: sinus of Valsalva aneurysm, thrombosis, myocardial infarction, stroke
A 71-year-old man with a history of hypertension was referred for primary percutaneous coronary intervention because of acute inferior myocardial infarction. In physical examination there was no neurological deficit, but the cooperation was poor. There was a grade 2/6 systolic ejection murmur over the right parasternal area. As we could not engage to the right coronary ostium, we performed unselective aortic root injection. During this injection, the right Judkins catheter engaged to right coronary artery (RCA) ostium after passing through a thrombus like mass and it showed RCA was occluded at ostium with a thrombus. After manual thrombus aspiration and dilatation with a 2.0 9 15 mm ryujin plus balloon, TIMI 3 flow was achieved and the procedure was completed. Both transthoracic echocardiography (TTE) and thoracic computed tomography (CT) showed a large thrombosed aneurysmatic dilatation of right sinus of Valsalva which caused an obstruction in right ventricular outflow tract with a gradient of 66/34 mmHg (Figs. 1–3, and movie clips S1–S3). There was no acute pathology in cranial CT of the patient which was performed due to the cooperation problem. Follow-up CT at 24th hour revealed multiple cerebral thromboemboli. The patient refused to have a surgical correction of the sinus Valsalva aneurysm and coronary stenosis. The patient discharged on aspirin, clopidogrel and warfarin treatment. Follow-up TTE at 4th week revealed the partial regression of the thrombus (movie clip S4). Address for correspondence and reprint requests: Abdulkadir Yildiz, M.D., Dicle University School of Medicine, Heart Hospital 21280 Sur, Diyarbakir, Turkey. Fax: +90 0412 248 84 40; E-mail: [email protected]
Aneurysm of the sinus of Valsalva (ASV) is defined as the dilatation of one of the three aortic sinuses between the aortic valve annulus, and the sinotubular junction or supra-aortic ridge.1 They can be congenital or acquired. Acquired aneurysms are caused by conditions affecting the aortic wall, such as infections (syphilis, bacterial endocarditis, or tuberculosis), trauma, or connective tissue disorders and usually ASV originates from the right coronary sinus in of patients.1,2 Aneurysms of the sinus of Valsalva are usually diagnosed after an acute rupture into an adjacent cardiac structure.1 Prior to rupture, ASV may present with conduction system abnormalities attributable to erosion into the interventricular septum, thromboembolism originating in the aneurysm sac,1 acute myocardial infarction,3 and right ventricular outflow tract obstruction.4 Embolic events due to unruptured ASV are uncommon. As in this case, large thrombus may occur within the aneurysm and depending on the thrombus variety of embolism may develop. In this case, it should be remembered that angiography catheter maneuvers could result with embolization of the thrombotic material. As the patient had cooperation disorder and acute chest pain at presentation in the present case, we thought that dynamic changes in the characteristics of the thrombus may result in simultaneous coronary and cerebral embolization. To our knowledge this is the first case of ASV thrombosis presented with both acute myocardial infarction and acute stroke, which teaches us thrombosed sinus of Valsalva aneurysms should be kept in mind in patients with acute coronary syndrome in case of accompanying cerebral condition. 189
Polat, et al.
Figure 1. Parasternal long- and short-axis view showing thrombotic right sinus of Valsalva aneurysm. AoV = aortic valve; LA = left atrium; LCC = left coronary cusp; LV = left ventricle; IVS = interventricular septum; NCC = noncoronary cusp; PA = main pulmonary artery; PW = posterior wall; RCC = right coronary cusp and asterisk (*) and arrows, thrombotic right sinus of Valsalva Aneurysm.
Figure 2. Color and continuous-wave Doppler demonstration of the right ventricular outflow tract obstruction. AoV = aortic valve; PA = main pulmonary artery.
Figure 3. A, B. Computed tomographic views demonstrating thrombotic right sinus of Valsalva aneurysm. Ao = ascending thoracic aorta; X = thrombotic right sinus of Valsalva aneurysm.
References 1. Feldman DN, Roman MJ: Aneurysms of the sinuses of Valsalva. Cardiology 2006;106:73–81. 2. Ott D: Aneurysm of the sinus of Valsalva. Semin Thorac Cardiovasc Surg Pediatr Card Surg Annu 2006;9:165– 176. 3. LaPorte F, Selton SC, Bonnemains L, et al: Acute myocardial infarction caused by sinus of Valsalva aneurysm. Echocardiography 2011;28:E19–E20. 4. Avci A, Akcakoyun M, Alizada E, et al: Severe right ventricular outflow obstruction by right sinus of valsalva aneurysm. Echocardiography 2010;27:341–343.
190
Supporting Information Additional Supporting Information may be found in the online version of this article: Movie clip S1. Parasternal long-axis view showing thrombotic right sinus of Valsalva aneurysm. Movie clip S2. Parasternal short-axis view showing thrombotic right sinus of Valsalva aneurysm.
Thrombotic ASV causing Coronary and Cerebral event
Movie clip S3. Color Doppler demonstration of the right ventricular outflow tract obstruction.
Movie clip S4. Follow-up transthoracic echocardiogram at 4th week showing partial regression of the thrombus in parasternal long-axis view.
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