Volume124 Number 6
Brief Communications
left superior vena cava. Only a few cases of coronary sinus type atrial septal defect have been diagnosed before surgery by detecting the defect of the septum from various views and identifying a shunt flow from the left atrium to the right atrium by means of TTE.5~6 Because coronary sinus type atria1 septal defect is difficult to diagnose by routine TTE, the presence of a coronary sinus type atria1 septal defect must be inferred from identification of dilated coronary sinus, increased flow from coronary sinus, and right ventricular volume overload. However, dilated coronary sinus can be caused by persistent left superior vena cava or anomalous pulmonary venous return draining into coronary sinus. In this case, size and location of atria1 septal defect and the presence of roof in the coronary sinus were confirmed by the longitudinal scan of TEE. The absence of anomalous pulmonary venous return was confirmed by demonstration that all pulmonary veins were draining into the left atrium, and the diagnosis of persistent left superior vena cava was excluded by contrast echocardiography. To the best of our knowledge, this is one of the first reported cases of coronary sinus type atrial septal defect that was diagnosed before surgery and demonstrates the usefuIness of TEE in the identification of this defect. REFERENCES
1. GoorDA, LilleheiCW.Congenital malformations of theheart: 2. 3.
4.
5
6
embryology,anatomy, and operative considerations.New York: Grune& Stratton, 1975:103-11. Lee ME, Sade RM. Coronarysinusseptaldefect:surgicalconsiderations. J Thorac CardiovascSurg197$78:563-g. RaghibG,RuttenbergHD, AndersonRC, AmplatzK, Adams P Jr, EdwardsJE. Terminationof left superiorvenacavain left atrium, atria1 septaldefect,andabsence of coronarysinus: a developmental complex. Circulation 1965;31:906-18. Quaegebeur J. Kirklin JW. Pacific0 AD. Baraeron LM Jr. &rgi&l experience with unroofed coronary sir&s. Ann Thorat Surg 1979;27:418-25. Takahashi H, Sakamoto T, Amano K, Hada Y, Serizawa T, Tomaru T, Kawauchi M, Furuta N, Furuse A, Asano K. Coronary sinustype atrial septaldefectdiagnosed by two-dimensional color Doppler echocardiography: a case report. J Cardiog 1985;15:1283-91. Konstantindes S, Van Tournout FAM, Bennett JM. Unroofed
coronarysinusassociated with atrial septaldefectandsignificant mitral regurgitation. 99:377-g.
J Thorac Cardiovasc Surg 1990;
Aneurysm of the noncoronary sinus of Valsalva ruptured into the left atrium Laure Cabanes,MD, Elias Garcia, MD, Christian VanDamme, MD, Alain Berrebi, MD, Patrick Donzeau-Gouge, MD, Jean Fouchard, MD, and Franqois Guerin, MD Paris, France
Aneurysms of the sinus of Valsalva are rare and usually rupture into the right chambersof the heart. We report a From the Department of Cardiology, Hopital Cochin, Rene DescartesUniversity. Reprint requests: Laure Cabanes, MD, Service de Cardiologie Hdpital Cochin, 27 Rue Saint Jacques, 75014 Paris, France. 4/4/41346
1659
caseof an aneurysm of the noncoronary sinusof Valsalva that ruptured into the left atrium. Diagnosiswas established before surgery by transesophagealechocardiography with color flow Doppler imaging. A 75-year-old woman was admitted to the hospital for treatment of severeexertional dyspnea. On examination, there wasa grade 4/6 continuous murmur, which washeard at the apex and radiating to the left axilla. Systolic and diastolic blood pressure were 140 and 40 mm Hg, respectively, and an increasedarterial pulsewasnoted. Moderate symptoms of congestive heart failure were present. ECG was normal, and a chest roentgenogram revealed a mild enlargement of the heart with evidence of pulmonary venous hypertension. Transthoracic echocardiography (Advanced Technology Laboratories, Inc., Bothell, Wash.), with a 2.25MHz transducer demonstrateda slight enlargement of the left ventricle with a good systolic contraction, (shorteningfraction, 35%). The left atrium wasdilated (45 mm in diameter). The aortic valve appearedto be normal. The aneurysm of the noncoronary sinus of Valsalva was detected in the parasternal and apical views, and a possible rupture was suspectedbecauseof a high-velocity flow, which was recorded throughout cardiac cycle in the left atrium with continuous wave Doppler echocardiography. The exact origin of this flow could not be identified with either pulsedwave or color flow Doppler echocardiography. Monoplane transesophagealechocardiography was performed with the sameequipment a 5 MHz transducer was used; a prominent deformity of the noncoronary sinusof Valsalva of 50 mm in diameter, which protruded into the left atrium was identified (Fig. 1). Furthermore, transesophagealechocardiographyclearly demonstrated a 7 mm dehiscenceof the wall of the aneurysm (Fig. 1) and color flow Doppler imaging showed a continuous mosaic jet, which flowed from the sinus and extended into the left atrium through this dehiscence(Fig. 2). Color flow Doppler imaging allowed direct visualization of systolic and diastolic filling of the aneurysm.There wasno evidence of any other abnormality commonly associatedwith aneurysmsof the sinus of Valsalva. The aortic leaflets appeared to be normal with no aortic regurgitation; there wasno ventricular septal defect, and coronary arteries were normal during the preoperative cardiac catheterization. The patient underwent a cardiopulmonary bypass:the aortic valve and the left and right coronary sinuswere normal. Elective repair of the posterior sinuswasundertaken: the defect was sutured, and the posterior sinus wasreconstructed with a Geseal’spatch (Vascutek Ltd., Renfrewshire, Scotland). The postoperative coursewas uneventful. Sinusof Valsalva aneurysmsarisefrom the noncoronary sinusin about 25% of casesand rupture more frequently into the right atrium or ventric1e.l However, perforation may occur in the left ventricle, the interventricular septum, a pulmonary artery, the superior vena cava, the pericardium, or the pleura. To our knowledge,this report may be the first oneto describea rupture of the noncoronary sinus of Valsalva aneurysm into the left atrium. Diagnosiswas established before surgery with transthorathoracic and transesophagealechocardiography. Previous reports outlined the usefulnessof Doppler echocardiography in the assessmentand managementof sinus of Valsalva aneu-
1660
Brief Communications
American
December 1992 HearI Journal
Fig. 1. Transesophageal four-chamber view showing the noncoronary sinus of Valsalva aneurysm protruding and ruptured into the left atrium. LA, Left atrium; LV, left ventricle; RA, right atrium; RV, right sinus of Valsalva. ventricle; AV, aortic valve; A, aneurysm of the noncoronary
Fig. 2. Transesophageal echocardiogram with color flow Doppler imaging. The high-velocity turbulent flow in the left atrium originates from the noncoronary sinus aneurysm. LV, Left ventricle; AO, aorta; A, aneurysm of the sinus of Valsalva.
rys1DlS. 2-5 Transthoracic echocardiography allowed us to est.2iblish the diagnosis of a noncoronary sinus of Valsalva ane surysm and its location in the left atrium. However, becau se of poor delineation of the aneurysm, perforation had not been detected. Transesophageal echocardiography con-
firmed transthoracic findings and diagnosed rupture ! of the aneurysm. Because of the proximity of the esophag us and the left atrium, the aneurysm was very precisely delineated. Two-dimensional imaging allowed direct vis ualization of the small defect, and color flow Doppler ir naging
Volume
124
Number
6
Brief Communications
showedthe abnormal shunt. We concludethat transesophagealechocardiography is an invaluable tool for preoperative diagnosisand characterization of the aneurysmand for assessment of associatedcardiac abnormalities when they are present. REFERENCES
1. SakakibaraS,KonnoS. Congenitalaneurysm of the sinus of Valsalva: anatomy
and classification.
AM
HEART
J 1962;
1661
3. Chow LC, Dittrich HC, Dembitsky WP, Nicod PH. Accurate localization of ruptured sinus of Valsalva aneurysm by real time two-dimensional Doppler flow imaging. Chest 1988; 94:462-5. 4. McKenney PA, Shemin RJ, Wiegers SE. Role of transesophageal echocardiography in sinus of Valsalva aneurvsm. 1$92;123:228-9. 5. Blackshear JL, Safford RE, Lane GE, Freeman WK, Schaff HV. Unruptured noncoronary sinus of Valsalva aneurysm: preoperative characterization by transesophageal echocardiography. J Am Sot Echocardiogr 1991;4:485-90.
63:405-24.
2. Chiang CW, Lin FC, Fang BR. Doppler and two-dimensional echocardiographic features of sinus of Valsalva aneurysm. AM HEART
J 1988;59:1283-8.
BOUND
VOLUMES
AVAILABLE
TO SUBSCRIBERS
Bound volumes of the AMERICAN HEART JOURNAL are available to subscribers (only) for the 1992 issues from the Publisher at a cost of $57.00 for domestic, $78.99 for Canadian, and $75.00 for international subscribers for Vol. 123 (January-June) and Vol. 124 (July-December). Shipping charges are included. Each bound volume contains a subject and author index and all advertising is removed. Copies are shipped within 60 days after publication of the last issue in the volume. The binding is durable buckram with the journal name, volume number, and year stamped in gold on the spine. Payment must accompany all orders. Contact Mosby-Year Book, Inc., Subscription Services, 11830 Westline Industrial Dr., St. Louis, MO 63146, USA; phone (800)325-417’7, ext. 4351, or (314)453-4351. Subscriptions must be in force to qualify. Bound volumes are not available in place of a regular Journal subscription.
I
I
Brief Communications
left superior vena cava. Only a few cases of coronary sinus type atrial septal defect have been diagnosed before surgery by detecting the defect of the septum from various views and identifying a shunt flow from the left atrium to the right atrium by means of TTE.5~6 Because coronary sinus type atria1 septal defect is difficult to diagnose by routine TTE, the presence of a coronary sinus type atria1 septal defect must be inferred from identification of dilated coronary sinus, increased flow from coronary sinus, and right ventricular volume overload. However, dilated coronary sinus can be caused by persistent left superior vena cava or anomalous pulmonary venous return draining into coronary sinus. In this case, size and location of atria1 septal defect and the presence of roof in the coronary sinus were confirmed by the longitudinal scan of TEE. The absence of anomalous pulmonary venous return was confirmed by demonstration that all pulmonary veins were draining into the left atrium, and the diagnosis of persistent left superior vena cava was excluded by contrast echocardiography. To the best of our knowledge, this is one of the first reported cases of coronary sinus type atrial septal defect that was diagnosed before surgery and demonstrates the usefuIness of TEE in the identification of this defect. REFERENCES
1. GoorDA, LilleheiCW.Congenital malformations of theheart: 2. 3.
4.
5
6
embryology,anatomy, and operative considerations.New York: Grune& Stratton, 1975:103-11. Lee ME, Sade RM. Coronarysinusseptaldefect:surgicalconsiderations. J Thorac CardiovascSurg197$78:563-g. RaghibG,RuttenbergHD, AndersonRC, AmplatzK, Adams P Jr, EdwardsJE. Terminationof left superiorvenacavain left atrium, atria1 septaldefect,andabsence of coronarysinus: a developmental complex. Circulation 1965;31:906-18. Quaegebeur J. Kirklin JW. Pacific0 AD. Baraeron LM Jr. &rgi&l experience with unroofed coronary sir&s. Ann Thorat Surg 1979;27:418-25. Takahashi H, Sakamoto T, Amano K, Hada Y, Serizawa T, Tomaru T, Kawauchi M, Furuta N, Furuse A, Asano K. Coronary sinustype atrial septaldefectdiagnosed by two-dimensional color Doppler echocardiography: a case report. J Cardiog 1985;15:1283-91. Konstantindes S, Van Tournout FAM, Bennett JM. Unroofed
coronarysinusassociated with atrial septaldefectandsignificant mitral regurgitation. 99:377-g.
J Thorac Cardiovasc Surg 1990;
Aneurysm of the noncoronary sinus of Valsalva ruptured into the left atrium Laure Cabanes,MD, Elias Garcia, MD, Christian VanDamme, MD, Alain Berrebi, MD, Patrick Donzeau-Gouge, MD, Jean Fouchard, MD, and Franqois Guerin, MD Paris, France
Aneurysms of the sinus of Valsalva are rare and usually rupture into the right chambersof the heart. We report a From the Department of Cardiology, Hopital Cochin, Rene DescartesUniversity. Reprint requests: Laure Cabanes, MD, Service de Cardiologie Hdpital Cochin, 27 Rue Saint Jacques, 75014 Paris, France. 4/4/41346
1659
caseof an aneurysm of the noncoronary sinusof Valsalva that ruptured into the left atrium. Diagnosiswas established before surgery by transesophagealechocardiography with color flow Doppler imaging. A 75-year-old woman was admitted to the hospital for treatment of severeexertional dyspnea. On examination, there wasa grade 4/6 continuous murmur, which washeard at the apex and radiating to the left axilla. Systolic and diastolic blood pressure were 140 and 40 mm Hg, respectively, and an increasedarterial pulsewasnoted. Moderate symptoms of congestive heart failure were present. ECG was normal, and a chest roentgenogram revealed a mild enlargement of the heart with evidence of pulmonary venous hypertension. Transthoracic echocardiography (Advanced Technology Laboratories, Inc., Bothell, Wash.), with a 2.25MHz transducer demonstrateda slight enlargement of the left ventricle with a good systolic contraction, (shorteningfraction, 35%). The left atrium wasdilated (45 mm in diameter). The aortic valve appearedto be normal. The aneurysm of the noncoronary sinus of Valsalva was detected in the parasternal and apical views, and a possible rupture was suspectedbecauseof a high-velocity flow, which was recorded throughout cardiac cycle in the left atrium with continuous wave Doppler echocardiography. The exact origin of this flow could not be identified with either pulsedwave or color flow Doppler echocardiography. Monoplane transesophagealechocardiography was performed with the sameequipment a 5 MHz transducer was used; a prominent deformity of the noncoronary sinusof Valsalva of 50 mm in diameter, which protruded into the left atrium was identified (Fig. 1). Furthermore, transesophagealechocardiographyclearly demonstrated a 7 mm dehiscenceof the wall of the aneurysm (Fig. 1) and color flow Doppler imaging showed a continuous mosaic jet, which flowed from the sinus and extended into the left atrium through this dehiscence(Fig. 2). Color flow Doppler imaging allowed direct visualization of systolic and diastolic filling of the aneurysm.There wasno evidence of any other abnormality commonly associatedwith aneurysmsof the sinus of Valsalva. The aortic leaflets appeared to be normal with no aortic regurgitation; there wasno ventricular septal defect, and coronary arteries were normal during the preoperative cardiac catheterization. The patient underwent a cardiopulmonary bypass:the aortic valve and the left and right coronary sinuswere normal. Elective repair of the posterior sinuswasundertaken: the defect was sutured, and the posterior sinus wasreconstructed with a Geseal’spatch (Vascutek Ltd., Renfrewshire, Scotland). The postoperative coursewas uneventful. Sinusof Valsalva aneurysmsarisefrom the noncoronary sinusin about 25% of casesand rupture more frequently into the right atrium or ventric1e.l However, perforation may occur in the left ventricle, the interventricular septum, a pulmonary artery, the superior vena cava, the pericardium, or the pleura. To our knowledge,this report may be the first oneto describea rupture of the noncoronary sinus of Valsalva aneurysm into the left atrium. Diagnosiswas established before surgery with transthorathoracic and transesophagealechocardiography. Previous reports outlined the usefulnessof Doppler echocardiography in the assessmentand managementof sinus of Valsalva aneu-
1660
Brief Communications
American
December 1992 HearI Journal
Fig. 1. Transesophageal four-chamber view showing the noncoronary sinus of Valsalva aneurysm protruding and ruptured into the left atrium. LA, Left atrium; LV, left ventricle; RA, right atrium; RV, right sinus of Valsalva. ventricle; AV, aortic valve; A, aneurysm of the noncoronary
Fig. 2. Transesophageal echocardiogram with color flow Doppler imaging. The high-velocity turbulent flow in the left atrium originates from the noncoronary sinus aneurysm. LV, Left ventricle; AO, aorta; A, aneurysm of the sinus of Valsalva.
rys1DlS. 2-5 Transthoracic echocardiography allowed us to est.2iblish the diagnosis of a noncoronary sinus of Valsalva ane surysm and its location in the left atrium. However, becau se of poor delineation of the aneurysm, perforation had not been detected. Transesophageal echocardiography con-
firmed transthoracic findings and diagnosed rupture ! of the aneurysm. Because of the proximity of the esophag us and the left atrium, the aneurysm was very precisely delineated. Two-dimensional imaging allowed direct vis ualization of the small defect, and color flow Doppler ir naging
Volume
124
Number
6
Brief Communications
showedthe abnormal shunt. We concludethat transesophagealechocardiography is an invaluable tool for preoperative diagnosisand characterization of the aneurysmand for assessment of associatedcardiac abnormalities when they are present. REFERENCES
1. SakakibaraS,KonnoS. Congenitalaneurysm of the sinus of Valsalva: anatomy
and classification.
AM
HEART
J 1962;
1661
3. Chow LC, Dittrich HC, Dembitsky WP, Nicod PH. Accurate localization of ruptured sinus of Valsalva aneurysm by real time two-dimensional Doppler flow imaging. Chest 1988; 94:462-5. 4. McKenney PA, Shemin RJ, Wiegers SE. Role of transesophageal echocardiography in sinus of Valsalva aneurvsm. 1$92;123:228-9. 5. Blackshear JL, Safford RE, Lane GE, Freeman WK, Schaff HV. Unruptured noncoronary sinus of Valsalva aneurysm: preoperative characterization by transesophageal echocardiography. J Am Sot Echocardiogr 1991;4:485-90.
63:405-24.
2. Chiang CW, Lin FC, Fang BR. Doppler and two-dimensional echocardiographic features of sinus of Valsalva aneurysm. AM HEART
J 1988;59:1283-8.
BOUND
VOLUMES
AVAILABLE
TO SUBSCRIBERS
Bound volumes of the AMERICAN HEART JOURNAL are available to subscribers (only) for the 1992 issues from the Publisher at a cost of $57.00 for domestic, $78.99 for Canadian, and $75.00 for international subscribers for Vol. 123 (January-June) and Vol. 124 (July-December). Shipping charges are included. Each bound volume contains a subject and author index and all advertising is removed. Copies are shipped within 60 days after publication of the last issue in the volume. The binding is durable buckram with the journal name, volume number, and year stamped in gold on the spine. Payment must accompany all orders. Contact Mosby-Year Book, Inc., Subscription Services, 11830 Westline Industrial Dr., St. Louis, MO 63146, USA; phone (800)325-417’7, ext. 4351, or (314)453-4351. Subscriptions must be in force to qualify. Bound volumes are not available in place of a regular Journal subscription.
I
I
