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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 Read More: http://www.ajronline.org/doi/abs/10.2214/AJR.09.3570 THANK YOU