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64 SLICE CT IN
ANEURYSM OF SINUS OF
VALSALVA
WITH A RARE COMPLICATION
-Once In A Blue Moon
ID NO:1208
Case 1:

33 yrs female with complaints of abdominal pain.

Evaluated pertaining to renal calculi revealed coronary
calcifications in CT.

Echo was done revealed cystic structure suggestive of left
ventricular free wall aneurysm and was referred for 64 slice
CT angiogram.
64 slice CT: Coronary angiogram
Left coronary sinus
Aneurysmal dilatation of
left coronary sinus with
extravasation of contrast
into
inter atrial and
interventricular region
with no communication
with chambers.
LA
Extravasated contrast
Coronal reconstruction:
Extravasation
LCA
Coronal
reconstruction
demonstrating
contrast
extravasation with
thrombus and no
communication with
chambers .
LV
RA
Demarcation from LV
Thrombus
Sagittal reconstruction:
Left atrium
Extravasated
contrast
Volume rendered image:
collection
LA
Descending aorta
collection
ascending aorta
Follow up: patient refused surgery and is under
conservative management
Case 2:

38 yrs male

Complaints of chest pain
-exertional
Aneurysm of ascending and
arch of aorta
Non coronary
sinus
Case 3:

40 yrs Female.

Complaints of
exertional chest pain.
Aneurysm non coronary
sinus
Sinus of Valsalva aneurysm:
Aortic root anatomy:

Separation of media of sinus Aortic root- valve leaflets,attachments,sinuses of
from media of adjacent hinge valsalva,interleaflet trigone,sinotubular junction and
line of AV valve cusp.
annulus.

Gives way under pressure to
form aneurysm.
Leaflets:freemargin,belly and basal attachment.
Attachments:annulus(thick crown shaped fibrous
structure)
Sinuses of valsalva:proximally attachment distally
ST junction.
Annulus: ventriculoaortic junction.
Aortic Root anatomy:
Complications:
Teaching point:

Rupture.

Myoardial infarct.

Heart block.

Right ventricular
outflow tract
obstruction.

Tamponade.

Sudden death.
Our case demonstrated rupture into
interventricular septum and inter atrial groove
with no aortocardiac shunts ,hence patient
asymptomatic without failure features.
Aneurysm rupture:

Right coronary sinus-65-85%.

Non coronary sinus-10-30%

Left coronary sinus-5%
Our case 1 had extracardiac
aneurysmal component in
interatrial groove
Teaching point:
Routes of rupture:
Right Sinus:Localised windsok->into adjacent low pressure chamber>intracardiac fistulous portion->nipple like projetion into chamber
Non coronary sinus: direct fistulous between sinus and heart.
Left sinus:extra cardiac aneurysm.
Clinial features:
Teaching point:

Depending on size of aneurysm.
 Rapidity.
 Cardiac chamber with which it
communicates.
Ruptured:
 20% no symptoms
 45% effort dyspnoea.
 35% acute dyspnoea,epigastric pain.
 Precipitated by heavy exertion,
Infective endocarditis/Marfan syndrome.
The clinical manifestations of
Valsalva sinus
aneurysms vary widely. When
symptoms are present,
they often are related to aneurysm
rupture
or mass effect on adjacent cardiac
structures
our case1 and 3 are
asymptomatic
Imaging aims:

Assess root-dimensions,regurgitations.

Aneurysm morphology- sinus of origin
,chamber of penetration, signs of
rupture.

Coronary arteries-origin .

Compression of tricuspid valve or
outflow tracts.

Associations:VSD, Bicuspid aortic
valve, Pulmonic stenosis, Coarctation,
ASD.

Any shunts.
MR:
Evaluate LV hemodynamics
Identify regurgitations and
quantify aortocardiac shunt or
fistulous flow.
CT:
is less time consuming.
Conventional angio:
gold standard.
Curved MPR windsock
communication with RA
Rupture
into right
atrium just
above
septal
tricuspid
leaflet
Aneurysm of left
coronary sinus
with serous
hemorrhagic
pericardial effusion
due to small defect
in
aneurysm[perop]
Few images from reference articles
Surgery indications:
Sudden Death:

Beyond 5.5cm

Progression>1cm/yr



• Tamponade
• Myocardial ischemia
Aortic regurgitation with ventricular
• Conduction disturbances and
enlargement.
arrythmias.
Unruptured aneurysm encroaching
• Rupture into pericardial space-very
nearby structures,ischemia,potential
rare 2% non coronary,invariably to
to rupture
tamponade-fatal.
Family history- dissection or rupture • Rupture causing compression of
ostium of left main coronary artery
causing ischemia and arrythmia.
Differential diagnosis:

Aortic root/ascending aortic aneurysm –above the
sinotubular ridge

Coronary AV fistula-coronaries and chamber

Prolapsed aortic cusps-below the annulus
Teaching point:
Hence our case2 with
ascending aortic aneurysm
involving root doesn’t
hold good
At imaging, the criteria for diagnosing a Valsalva
sinus aneurysm include
• an origin above the aortic
annulus
• a saccular shape, and
• normal dimensions of the adjacent aortic root
and ascending aorta
Conclusion:

In summary Sinus of Valsalva aneurysm is a rare
presentation that enlarges and can rupture as a complication.

Initial diagnosis is suspected by colour echocardiography ,
but its origin, course ,route of fistulous tract can be precisely
demonstrated with CT angiography.

CT angiography provides a comprehensive cardiac
evaluation including evaluation of coronary artery and
presence of associated cardiac anomalies.
References:

www.researchgate.net/...Valsalva_sinus.../09e4150be4f81d9fc2
000000
 Feldman DN, Roman MJ. Aneurysms of the sinus of
Valsalva. Cardiology. 2006;106:73–81. [PubMed]
 http://www.revespcardiol.org/en/rupture-of-left-sinusof/articulo/13152404/

Thurman J. On aneurisms, and especially spontaneous varicose
aneurisms of the ascending aorta, and sinuses of Valsalva: with
cases. Med Chir Tr 1840; 23:323–384
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More: http://www.ajronline.org/doi/abs/10.2214/AJR.09.3570
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