Download Ruptured Coronary Sinus Aneurysm

NOVEMBER 2012
ISSUE 50
Ruptured Coronary Sinus Aneurysm
Ali Karaosmanoglu, MD, Mannudeep Kalra, MD; Sarah Tsiaras, MD; Vishnu Vanaharam, MD; Wilfred Mamuya, MD, PhD;
Suhny Abbara, MD
Clinical History
A 36 year old man presented to his primary care physician with
exercise intolerance and shortness of breath, and was found to
have a heart murmur. A transthoracic echocardiography revealed
a question of supracristal ventricular septal defect. A cardiac
CTA was requested to further delineate the anatomy and exclude
obstructive coronary artery disease.
Findings
CT angiography of the coronary arteries and the ascending aorta
demonstrated the presence of an 8 mm defect between the wall
of the right sinus of Valsalva and the right ventricle (figures 1,2)
resulting in a left to right shunt. A transesophageal echocardiography
performed at the day of the surgery confirmed a large abnormal
communication between the right sinus of Valsalva and the right
ventricle, consistent with a ruptured sinus of Valsalva aneurysm and a
small supracristal ventricular septal defect. There was no associated
fluid in the pericardial cavity to suggest extra-cardiac rupture.
Figure 1A
Figure 1B
Figure 2A
Figure 2B
The ruptured sinus of Valsalva aneurysm and small conal ventricular
septal defect were closed surgically without complications.
Discussion
Sinuses of Valsalva are focal expansions of the aortic root and
located between the aortic annulus and the sinotubular junction.
The coronary arteries originate from the right and left sinuses of
Valsalva, with no vessel arising from the non-coronary sinus. These
sinuses provide a space behind the valve leaflets when the leaflets
are open so that the coronary artery ostia do not get obstructed.
Sinus of Valsalva aneurysms most commonly originate from
the right coronary sinus in 70-80% and less commonly from
the non coronary (10-20%) and left sinuses (<5%) and may be
congenital or acquired. Congenital aneurysms are thought to
result from localized weaknesses of the elastic lamina and can
be seen in patients with Marfan and Ehlers-Danlos syndrome.
Acquired aneurysms can be seen in patients with tuberculosis,
syphilis, atherosclerosis, cystic medial necrosis or trauma.
The main complications associated with these aneurysms are
rupture, arrhythmias, outflow tract obstruction and endocarditis.
Clinical symptoms vary in a wide spectrum from asymptomatic to
hemodynamic collapse and sudden cardiac death. Surgical repair
is the mainstay of the treatment with excellent survival rates.
Editors:
Suhny Abbara, MD, MGH Department of Radiology
Figure 1(A,B): Corresponding gray scale echocardiography (A)
and 3 chamber reformatted CTA images demonstrates an abnormal
communication between the right coronary sinus and the right ventricle
through a defect in the right coronary sinus (arrows in both images). LV:
left ventricle, RV: right ventricle, AO: Aorta.
Figure 2(A,B): Corresponding color Doppler echocardiography (A)
and CTA (B) images show the abnormal communication between
the right coronary sinus and the right ventricle (white arrows in both
images). Also note the jet flow from the left ventricular outflow tract
towards the right ventricle. LV: left ventricle, RV: right ventricle, AO:
REFERENCES
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Roentgenol;194:495504
3. Bricker AO, Avutu B, Mohammed TL, Williamson EE, Syed IS,
Julsrud PR, Schoenhagen P, Kirsch J. Valsalva sinus aneurysms:
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Wilfred Mamuya, MD, PhD, MGH Division of Cardiology