© 2015, Wiley Periodicals, Inc. DOI: 10.1111/echo.12950
Echocardiography
IMAGE SECTION
Giant Aneurysm of Aortic Right Coronary Sinus: Diagnostic Doubts Related to Presentation of Valsalva Sinus Aneurysm in Transthoracic Echocardiography Karina Wierzbowska-Drabik, M.D., Ph.D, Jarosław D. Kasprzak, M.D., Ph.D., F.E.S.C., F.A.C.C., Konrad Szymczyk, M.D., Ewa Szymczyk, M.D., Ph.D., Katarzyna Wdowiak-Okrojek, M.D., and Piotr Lipiec, M.D., Ph.D., F.E.S.C. Chair and Department of Cardiology, Medical University of Lodz, Lodz, Poland
(Echocardiography 2015;00:1–2) Key words: aneurysm of Valsalva sinus, transthoracic echocardiography, computed tomography
Case Description: Seventy-nine-year-old woman with permanent atrial fibrillation and scoliosis was admitted to the Department of Internal Diseases because of effort intolerance and back pain. Her physical examination revealed body mass index 20 kg/m2, small body surface area 1.38 m2, and systolic murmur over the heart. Transthoracic echocardiography (TTE) indicated confusing oval structure filling the right ventricle and the lack of aortic wall in the parasternal long-axis view which raised the suspicion of some septal or artery wall defect (Figs. 1–2). Considering these doubts, the patient was transferred to Cardiology Department. Detailed 2D and 3DTTE demonstrated huge aneurysm of right Valsalva sinus causing dilatation of aorta reaching 73 mm, which modeled right ventricle (RV) and was seen as oval structure filling RV cavity. Interestingly, aortic annulus was not dilated (23 mm) with only mild aortic insufficiency. Color Doppler did not corroborate septal defect but indicated on turbulent flow inside RV (Fig. 3 and movie clip S1). Computed tomography confirmed the diagnosis of unruptured aneurysm of right aortic sinus (Fig. 4). Our case is atypical due to relatively large dimensions of aneurysm, which seemed to fill completely RV cavity and was misdiagnosed by less experienced echocardiographer. Address for correspondence and reprint requests: Karina Wierzbowska-Drabik, M.D., Ph.D., Chair and Department of Cardiology, Medical University of Lodz, Kniaziewicza 1/5, 91-347 Lodz, Poland. Fax: +48422516015; E-mail: [email protected]
Aneurysm of Valsalva sinus (SVA) is a rare, usually congenital anomaly, sometimes connected with supracristal VSD, although traumatic, infective, and inflammatory origins were also described.1 Unruptured SVA may be asymptomatic, cause RV outflow tract obstruction, compress coronary arteries, or lead to thrombotic complications—acute coronary syndrome or stroke.2,3 Surgical and percutaneous interventions with occluding devices are applied in patients with SVA.4
Figure 1. Presentation of SVA in 2D parasternal long-axis view (LAX) suggesting “lack of aortic wall” over interventricular septum (red arrow) which in the reality corresponds with the neck of right Valsalva sinus aneurysm. Ao = ascending aorta; LA = left atrium; LV = left ventricle; RV = right ventricle; SVA = sinus Valsalva aneurysm.
1
Wierzbowska-Drabik, et al.
Figure 2. Aneurysm of right Valsalva sinus mimicking “oval structure in the cavity of right ventricle”—presentation in 2D parasternal short-axis view (SAX) on the level of mitral valve. MV = mitral valve; SVA = sinus Valsalva aneurysm; TV = tricuspid valve
Figure 3. Presentation of SVA in color Doppler echocardiography in parasternal long-axis view. Arrows indicate SVA and its neck without flow of significant velocity as well as turbulent diastolic flow in right ventricle related to the obstruction of RV cavity with SVA and mild, central aortic regurgitation. AR = aortic regurgitation; SVA = sinus Valsalva aneurysm; RV = right ventricle.
References 1. Hartlage GR, Consolini MA, Pernetz MA, et al: Bad company: supracristal VSD presenting with ruptured sinus of
2
Figure 4. Presentation of SVA in computed tomography. 2D presentation shows the compression of right ventricular outflow tract with SVA. LA = left atrium; LCA = left coronary artery; NCS = noncoronary sinus; PA = pulmonary artery; RCA = right coronary artery; RVOT = right ventricular outflow tract; SVA =sinus Valsalva aneurysm.
Valsalva aneurysm. A case presentation with echocardiographic depiction and an analysis of contemporary literature. Echocardiography 2015;32:575–583. 2. Chung E, Baek JY, Chung HH, et al: A case of unruptured aneurysm of the right sinus of Valsalva with right ventricular outflow obstruction. Korean Circ J 2014;44:274–277. 3. Polat N, Yildiz A, Yuksel M, et al: A thrombotic right sinus of valsalva aneurysm causing acute myocardial infarction and ischemic stroke. Echocardiography 2015;32:189–191. 4. Mizia-Stec K, Haberka M, Mielczarek M, et al: Recurrent rupture of a sinus of Valsalva aneurysm in a patient with a bicuspid aortic valve treated with percutaneous implantation of an Amplatzer occluder. Kardiol Pol 2008;66:344– 34.
Supporting Information Additional Supporting Information may be found in the online version of this article: Movie clip S1. SVA in long-axis view mimicking “defect of aortic wall.”
Echocardiography
IMAGE SECTION
Giant Aneurysm of Aortic Right Coronary Sinus: Diagnostic Doubts Related to Presentation of Valsalva Sinus Aneurysm in Transthoracic Echocardiography Karina Wierzbowska-Drabik, M.D., Ph.D, Jarosław D. Kasprzak, M.D., Ph.D., F.E.S.C., F.A.C.C., Konrad Szymczyk, M.D., Ewa Szymczyk, M.D., Ph.D., Katarzyna Wdowiak-Okrojek, M.D., and Piotr Lipiec, M.D., Ph.D., F.E.S.C. Chair and Department of Cardiology, Medical University of Lodz, Lodz, Poland
(Echocardiography 2015;00:1–2) Key words: aneurysm of Valsalva sinus, transthoracic echocardiography, computed tomography
Case Description: Seventy-nine-year-old woman with permanent atrial fibrillation and scoliosis was admitted to the Department of Internal Diseases because of effort intolerance and back pain. Her physical examination revealed body mass index 20 kg/m2, small body surface area 1.38 m2, and systolic murmur over the heart. Transthoracic echocardiography (TTE) indicated confusing oval structure filling the right ventricle and the lack of aortic wall in the parasternal long-axis view which raised the suspicion of some septal or artery wall defect (Figs. 1–2). Considering these doubts, the patient was transferred to Cardiology Department. Detailed 2D and 3DTTE demonstrated huge aneurysm of right Valsalva sinus causing dilatation of aorta reaching 73 mm, which modeled right ventricle (RV) and was seen as oval structure filling RV cavity. Interestingly, aortic annulus was not dilated (23 mm) with only mild aortic insufficiency. Color Doppler did not corroborate septal defect but indicated on turbulent flow inside RV (Fig. 3 and movie clip S1). Computed tomography confirmed the diagnosis of unruptured aneurysm of right aortic sinus (Fig. 4). Our case is atypical due to relatively large dimensions of aneurysm, which seemed to fill completely RV cavity and was misdiagnosed by less experienced echocardiographer. Address for correspondence and reprint requests: Karina Wierzbowska-Drabik, M.D., Ph.D., Chair and Department of Cardiology, Medical University of Lodz, Kniaziewicza 1/5, 91-347 Lodz, Poland. Fax: +48422516015; E-mail: [email protected]
Aneurysm of Valsalva sinus (SVA) is a rare, usually congenital anomaly, sometimes connected with supracristal VSD, although traumatic, infective, and inflammatory origins were also described.1 Unruptured SVA may be asymptomatic, cause RV outflow tract obstruction, compress coronary arteries, or lead to thrombotic complications—acute coronary syndrome or stroke.2,3 Surgical and percutaneous interventions with occluding devices are applied in patients with SVA.4
Figure 1. Presentation of SVA in 2D parasternal long-axis view (LAX) suggesting “lack of aortic wall” over interventricular septum (red arrow) which in the reality corresponds with the neck of right Valsalva sinus aneurysm. Ao = ascending aorta; LA = left atrium; LV = left ventricle; RV = right ventricle; SVA = sinus Valsalva aneurysm.
1
Wierzbowska-Drabik, et al.
Figure 2. Aneurysm of right Valsalva sinus mimicking “oval structure in the cavity of right ventricle”—presentation in 2D parasternal short-axis view (SAX) on the level of mitral valve. MV = mitral valve; SVA = sinus Valsalva aneurysm; TV = tricuspid valve
Figure 3. Presentation of SVA in color Doppler echocardiography in parasternal long-axis view. Arrows indicate SVA and its neck without flow of significant velocity as well as turbulent diastolic flow in right ventricle related to the obstruction of RV cavity with SVA and mild, central aortic regurgitation. AR = aortic regurgitation; SVA = sinus Valsalva aneurysm; RV = right ventricle.
References 1. Hartlage GR, Consolini MA, Pernetz MA, et al: Bad company: supracristal VSD presenting with ruptured sinus of
2
Figure 4. Presentation of SVA in computed tomography. 2D presentation shows the compression of right ventricular outflow tract with SVA. LA = left atrium; LCA = left coronary artery; NCS = noncoronary sinus; PA = pulmonary artery; RCA = right coronary artery; RVOT = right ventricular outflow tract; SVA =sinus Valsalva aneurysm.
Valsalva aneurysm. A case presentation with echocardiographic depiction and an analysis of contemporary literature. Echocardiography 2015;32:575–583. 2. Chung E, Baek JY, Chung HH, et al: A case of unruptured aneurysm of the right sinus of Valsalva with right ventricular outflow obstruction. Korean Circ J 2014;44:274–277. 3. Polat N, Yildiz A, Yuksel M, et al: A thrombotic right sinus of valsalva aneurysm causing acute myocardial infarction and ischemic stroke. Echocardiography 2015;32:189–191. 4. Mizia-Stec K, Haberka M, Mielczarek M, et al: Recurrent rupture of a sinus of Valsalva aneurysm in a patient with a bicuspid aortic valve treated with percutaneous implantation of an Amplatzer occluder. Kardiol Pol 2008;66:344– 34.
Supporting Information Additional Supporting Information may be found in the online version of this article: Movie clip S1. SVA in long-axis view mimicking “defect of aortic wall.”
