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Sinus of valsalva aneurysm(SVA) is a rare cardiac anomaly which may be congenital or acquired, and is missed diagnosis frequently because the unrupture aneurysm is always asymptomatic. To report a case of coronary sinus aneurysm rupture into the right atrium and review the diagnosis and management strategies for this disease.
A 25-year-old male patient was admitted to our hospital because of recurrent palpitations and chest tightness lasting for 10 days. He was in New York Heart Association class II, with a heart rate of 108 bpm and normal blood pressure on admission. Other physical exams were benign except for a grade III/VI systolic and diastolic continuous murmur over 3/4th intercostal space on left sternal border and apical. Echocardiography revealed noncoronary sinus of valsalva aneurysm rupture into the right atrium, localized mitral insufficiency, and normal left ventricular ejection fraction (EF67%).
The patient underwent transcatheter closure of ruptured SVA 3days after admission. Ascending aorta angiography in operation revealed a noncoronary aortic sinus aneurysm ruptured into the right atrium. Repeated angiography showed no residual shunt after implantation of the occluder. The clinical manifestation of this patient was improved after the transcatheter closure. Echocardiography was rechecked 2days and 8days after, indicated that the location of the occluder was normal and no residual shunt was detected.
SVA is an unusual cardiac anomaly congenital or acquired secondary to infections, degenerative disease or trauma, and manifests as the separation between the aortic media and annulus fibrous. Most of them are located in the right coronary sinus and rarely happen in noncoronary or left coronary sinus. It may induce complications such as ruptrue,right ventricular outflow tract obstruction, infective endocarditis, malignant arrhythmias and myocardial ischemia. Among them rupture is the most common one, which induce aorto-cardiac shunt or left to right shunt if ruptured into right cardiac chambers, and acute progressive heart failure. There are also a few cases of SVA protruding and broken into the pericardium, left ventricular and pulmonary artery. The challenge of early diagnosis is that most unrupture aneurysms are asymptomatic or display nonspecific symptoms including exertional dyspnea,palpitation,chest pain, syncope and cardiac murmurs. The diagnosis of SVA mainly relies on echocardiography, cardiac computed tomography or magnetic resonance imaging. Percutaneous transcatheter aortic angiography is useful in confirming the diagnosis and the hemodynamic changes of the lesion, evaluating precisely the associated cardiac anomalies and interventional treatment of occlusion. We aim to emphasize the vital importance of experience that early echocardiography should be performed in suspicious patients for timely diagnosis and intervention, to reduce the risk of rupture. Intervention of aneurysm including percutaneous transcatheter closure and direct surgical suturing is generally recommended for the optimal choice, depending on defect size, the quality of the tissues and whether combined with other structural anomalies. Urgent surgical intervention is recommended for intrapericardial rupture. Aortic valve replacement is generally required when aortic regurgitation present, and full aortic root replacement might be necessary if the lesion involve extensive or distort the aortic root.