Ruptured aneurysm of the right sinus of valsalva associated with a ventricular septal defect and an anomalous coronary artery

Aneurysms of the sinus of Valsalva are extremely rare. Ruptured aneurysms of the sinus of Valsalva are frequently associated with other congenital defects, particularly with ventricular septal defect, aortic valve regurgitation, and bicuspid aortic valve. We describe the case of a 26-year-old man who had a ruptured aneurysm of the right coronary sinus, a ventricular septal defect, and an anomalous origin of the right coronary artery. Successful surgical correction of the aneurysm and ventricular septal defect was performed with patch repair and aortic valve replacement. A review of the English-language medical literature revealed only 1 other case of a sinus of Valsalva aneurysm associated with a ventricular septal defect and an anomalous coronary artery. Previously published reports of the coexistence of a single coronary artery with a sinus of Valsalva aneurysm or with a ventricular septal defect, and their management, are discussed herein.     

Origin of the right from the left main coronary artery (single coronary ostium in aorta)

Origin of both the right and left main (LM) coronary arteries from the aortic wall of the right sinus of Valsalva frequently is a lethal anomaly.¹ Origin of both the right and LM coronary arteries from the aortic wall of the left sinus of Valsalva, in contrast, usually is a benign anomaly.² Although many studies have described origin of both LM and right coronary arteries from the aortic wall of the same sinus of Valsalva, few^1,2 have described origin of the right coronary artery from the LM. Husaini et al³ described angiographic features of this anomaly in a 52-year-old man who underwent selective coronary angiography after probable acute myocardial infarction. Muus and McManus⁴ described this anomaly in a fullterm stillborn infant who also had a bicuspid aortic valve. Whether the coronary anomaly played a role in the stillbirth is uncertain. In both of these previously described patients, the anomalously arising right coronary artery coursed between aorta posteriorly and the pulmonary trunk anteriorly.     

Unruptured aneurysm of the sinus of valsalva with Beh?et's disease.

A 52-year-old Japanese man who had suffered from Beh?et's disease since the age of 45 years was admitted to hospital for evaluation of syncope and heart murmur. Echocardiography and aortography revealed severe aortic regurgitation and cystic masses under the right coronary cusp and the left ventricular outflow tract, but no shunt jet. He was diagnosed with unruptured aneurysm of the sinus of Valsalva, and surgical closure of the orifice of the aneurysm was performed. The diameter of the orifice was 11 mm and the aneurysm was 15 mm in depth, and consisted of 2 chambers. Because the aortic regurgitation was reduced after patch closure of the orifice, aortic valve replacement was not performed. Unruptured aneurysm of the sinus of Valsalva is a rare clinical lesion, but patients with active inflammatory disease of the aorta, such as in Beh?et's disease, should have periodic echocardiography for early detection of an aneurysm or valvular involvement, even if there are not any symptoms.     

Anomalous origin of the right coronary artery from the ascending aorta: case history

A patient is described with an anomalous right coronary artery arising high above the left sinus of Valsalva. This patient is unique because the other 2 cases with such an anomalous origin of a right coronary artery had bicuspid aortic with such an anomalous origin of a right coronary artery had bicuspid aortic valves; this patient had a normal tricuspid aortic valve.     

A rare case of infective aneurysm involving all three sinuses of Valsalva complicated by left single coronary artery

Infective aneurysm showing dilatation of all three coronary sinuses of Valsalva due to infective endocarditis is extremely rare. We present the first report of such a case complicated by left single coronary artery. The patient was a 55-year-old man with a past history of untreated diabetes mellitus, cerebral infarction, aortic regurgitation and high-grade fever. He was admitted with a complaint of easy fatigability. In a treadmill exercise test, asymptomatic ischemic depression of the ST segment was observed. Two-dimensional echocardiography revealed marked dilatation of all three sinuses of Valsalva, and a mural thrombus within the dilated right sinus of Valsalva. On magnetic resonance imaging, an abnormal signal in the markedly dilated right sinus of Valsalva was revealed. Coronary arteriography showed left single coronary artery (L1 type by Sharbaugh's classification). The histopathological features of the affected aorta were thought to represent the healing stage of infective endocarditis. With regard to the myocardial ischemia in this patient, it was thought to have arisen mainly through aortic regurgitation and coronary atherosclerosis due to single coronary artery, and partly influenced by untreated diabetes mellitus.     

Origin of both coronary arteries from the same sinus of valsalva: Report of two cases

Origin of both coronary arteries from the same sinus of Valsalva was found in two patients. In one patient the right coronary artery opened from the left sinus of Valsalva, coursed between the pulmonary artery and aorta, disclosed a 95% obstruction in its proximal third with good runoff. The portion of the artery between the aorta and pulmonary artery showed cyclic narrowing during systole. In the second patient the left coronary opened from the right sinus of Valsalva, the left main trunk crossed anteriorily the pulmonary artery conus, and both the circumflex and the left anterior descending branches showed significant narrowing. In both patients the arteries shared a common sinus with two separate orifices, both had a bicuspid aortic valve, and in both, nonaberrant coronary vessels also had stigmata of atherosclerosis.     

Sinus of Valsalva Pseudoaneurysm as a Sequela to Infective Endocarditis

Pseudoaneurysm is an uncommon sequela of infective endocarditis. We treated a 44-year-old man who had an active case of group B streptococcal infective endocarditis of the aortic valve despite no evidence of valvular dysfunction or vegetation on his initial transesophageal echocardiogram. After completing 6 weeks of intravenous antibiotic therapy, the patient developed a sinus of Valsalva pseudoaneurysm and severe aortic regurgitation caused by partial detachment of the left coronary cusp.We used a pericardial patch to close the pseudoaneurysm and repair the coronary cusp. This case shows the importance of routine clinical follow-up evaluation in infective endocarditis, even after completion of antibiotic therapy. Late sequelae associated with infective endocarditis or its therapy include recurrent infection, heart failure caused by valvular dysfunction (albeit delayed), and antibiotic toxicity such as aminoglycoside-induced nephropathy and vestibular toxicity.     

Aorto-right artrial fistula: a rare complication of aortic dissection

We describe the successful surgical repair of an acute aortic dissection that had caused an aorto-right atrial fistula in a 67-year-old man. The patient was admitted to the hospital on an emergency basis because of severe heart failure. The diagnosis of acute aortic dissection with rupture into the right atrium was confirmed by use of intraoperative transesophageal echocardiography, although rupture of a sinus of Valsalva aneurysm into the right atrium had been suggested initially by 2-dimensional and Doppler transthoracic echocardiography. At surgery, we found the patient to have aortic arch dissection with complete separation of the right coronary artery from the sinus of Valsalva and a false lumen that had ruptured into the right atrium. The aortic arch was repaired directly. The ascending aorta was successfully replaced with a composite graft. Aortic dissection with rupture into the right atrium is extremely rare and leads to death rapidly. As shown in this case, such a condition might be mistaken for an aneurysmal rupture of the sinus of Valsalva, with use of transthoracic echocardiography alone. Transesophageal echocardiography is a useful noninvasive method to further define or confirm the diagnosis. Early surgical intervention is necessary in patients with this condition to prevent profound shock and end-organ failure.     

Post-Traumatic Pseudoaneurysm of the Left Sinus of Valsalva Revealed by an Acute Coronary Compression

A 69-year-old woman presented with chest pain and electrocardiographic evidence ofsubacute anterior ischaemia. Transthoracic and transesophageal echocardiography allowed correct diagnosis of a post-traumatic pseudoaneurysm of the left sinus of Valsalva. The large pseudoaneurysm caused compression of the left main coronary artery and was successfully treated by aortic root replacement, left main coronary artery ligation, and arterial bypass.     

Pseudoaneurysm of the non‐coronary sinus of Valsalva: A rare complication of percutaneous coronary intervention

Pseudoaneurysm of the non‐coronary sinus of Valsalva is an exceptionally rare but potentially fatal complication of percutaneous coronary interventions (PCI). Here, we report a case of a 53‐year‐old man with pseudoaneurysm of the non‐coronary sinus of Valsalva following PCI who presented with recurrent chest pain and was treated successfully by closure of the orifice of the pseudoaneurysm and coronary artery bypass grafting.     

Post-Traumatic Pseudoaneurysm of the Left Sinus of Valsalva Revealed by an Acute Coronary Compression: An Echocardiographic Case Report

A 69-year-old woman presented with chest pain and electrocardiographic evidence of subacute anterior ischaemia. Transthoracic and transesophageal echocardiography allowed correct diagnosis of a posttraumatic pseudoaneurysm of the left sinus of Valsalva. The large pseudoaneurysm caused compression of the left main coronary artery and was successfully treated by aortic root replacement, left main coronary artery ligation, and arterial bypass.     

Congenital quadricuspid aortic valve associated with severe regurgitation

A 56-year-old man was referred because of severe aortic regurgitation. He had a quadricuspid aortic valve with a small accessory cusp between the right coronary and noncoronary cusps. The ostium of the right coronary artery was deviated toward the accessory cusp commissure. Aortic valve replacement was performed with a bioprosthesis. The resected cusps showed fibrotic thickening with calcification and fenestration.     

Alternative Surgical Approach to Repairing a Giant Sinus of Valsalva Aneurysm

We report our method of surgically repairing an unruptured giant aneurysm of the right coronary sinus of Valsalva, a lesion that caused moderate aortic regurgitation but no symptoms in a 61-year-old woman. We excised the aneurysm, reconstructed the right sinus of Valsalva with use of a patch, performed mechanical aortic valve replacement directly through the excised aneurysm''s cavity, and constructed a single bypass graft to the right coronary artery. The patient was discharged from the hospital after 5 days. Twelve months postoperatively, her clinical and echocardiographic results were normal, and she was doing well. To our knowledge, our surgical approach to this repair has not been described previously.     

Unruptured aneurysm of the left sinus of valsalva causing coronary insufficiency: case report and review of the literature

Aneurysm of the left sinus of Valsalva is extremely rare. Compression of the left coronary artery by such an aneurysm is an unusual complication of this condition and can cause coronary insufficiency. We describe the case of a 75-year-old woman who had an isolated unruptured aneurysm of the left coronary sinus with intraluminal thrombus, which caused coronary artery compression. We performed successful surgical correction by closing the mouth of the aneurysm without aortic valve replacement or coronary artery bypass grafting. A review of the world medical literature revealed 19 cases of sinus of Valsalva aneurysms that hindered the coronary arterial flow. The previously published reports of this rare condition and its treatment are discussed herein.     

Anomalous origin of the left circumflex coronary artery: A case report

The anomalous origin of the left circumflex coronary artery from the right sinus of Valsalva is a relatively common anatomical variation. Difficulties may occur in the diagnostic procedure, but recognition and adequate visualization of the anomaly is essential for proper patient management, especially in patients undergoing evaluation for percutaneous coronary intervention, coronary artery surgery or prosthetic valve replacement. In the present report, a patient who had undergone percutaneous coronary intervention for a right coronary artery lesion after inferior myocardial infarction is described. The anomalous origin of the left circumflex coronary artery arising independently from the right sinus of Valsalva was previously undetected.     

Reoperation for early failure of a freestyle bioprosthesis using a full root technique

The case is reported of a 65-year-old male who required reoperation for early failure of a Freestyle stentless valve aortic root bioprosthesis implanted using the full root technique. The bioprosthesis had been implanted to treat annuloaortic ectasia associated with severe aortic regurgitation (AR). At 18 months postoperatively, a new diastolic murmur developed, though without complaint by the patient. Transthoracic echocardiography demonstrated severe AR with aneurysmal dilatation of the non-coronary porcine sinus of Valsalva. Pseudoaneurysm formation, associated with perforation of the non-coronary sinus of Valsalva of the bioprosthesis, was observed at surgery. On inspection, the pseudoaneurysm had pushed the commissures inward, and had created severe aortic valve regurgitation. No infection or calcification was detected on the Freestyle valve, and the aortic root was successfully reconstructed using a composite graft.     

Unruptured congenital aneurysm of the left sinus of Valsalva in an adult with complex left heart malformations

A 26 year old man who presented with the first signs of right heart failure was found to have a large congenital aneurysm of the aortic sinus of Valsalva and of the left coronary sinus. These were combined with left heart anomalies in the form of a bicuspid aortic valve, a rare variant of a persistent left superior vena cava with blood flow from the left atrium through the brachiocephalic vein into the superior vena cava and a kink in the aortic arch. An aortic coarctation had been corrected with a patch 12 years earlier. Although the aneurysm was not perforated and there were no clinical signs of infarction, the aneurysm was resected prophylactically and the left coronary artery was reinserted through a bypass with a Gore-Tex conduit. The case is noteworthy because this diagnosis is very rare and its early treatment may prevent several complications. The clinical features, treatment, and outcome are discussed.     

Anomalous origin of the right coronary high above the left sinus of Valsalva

Anomalous origin of the right coronary artery from the ascending aorta above the left sinus of Valsalva is exceedingly rare and previously has been reported to be associated with congenital aortic valve disease. We report a case of the right coronary artery arising from the mid ascending aorta, high above the left sinus, with a clinically and angiographically normal aortic valve.     

Anomalies of the coronary arteries originating from the right sinus of Valsalva. (1) Single coronary artery originating from the right sinus associated with fusion of the left and the non coronary cusp and atrophy of the left coronary ostium (2)Three separate coronary arteries originating from the right sinus of Valsalva

We report three patients with the entire coronary origin arising from the right sinus of Valsalva. The first patient had a single right coronary ostium associated with a bi-leaflet aortic valve. The second patient was admitted with ST-elevation myocardial infarction (STEMI) for primary PCI. The third patient had 3 isolated ostia, all originating from the right sinus of Valsalva. Coronary anomalies are associated with increased mortality, depending on the myocardium at risk. A left main originating from the right coronary sinus is supplying a greater extent of the myocardium and is associated both with an increased incidence of symptoms and of sudden cardiac death. The possibility of such an artery anomaly should always be considered in young individuals with a history of chest pain or syncope.     

Sinus of valsalva aneurysm with congenital aortic stenosis and aortic coarctation

A 52-year-old female was diagnosed with the extremely rare combination of sinus of Valsalva aneurysm, congenital unicuspid aortic valve stenosis, and coarctation of the aorta. She was successfully treated in a two-stage operation. The first operation consisted of a bypass graft to correct the coarctation. The second, performed 31 days later, included aortic valve replacement, patch closure of the aneurysm, and translocation of the right coronary artery.