A case report: a rare case of severe aortic incompetence

Abstract

Background: Aneurysms of the sinus of Valsalva (SOV) are thin-walled outpouchings most commonly involving the right or non-coronary sinuses. Because they are asymptomatic, they are rarely discovered before they rupture and form an aorto-cardiac fistula. We present a rare case of unruptured aneurysm of the right coronary SOV burrowing into the interventricular septum with severe aortic incompetence and left ventricular dysfunction. To our knowledge, burrowing of the SOV aneurysm (SVA) into the interventricular septum and its large sac-like appearance has never been described using three dimensional (3D) echocardiography before.

Case summary: A 37-year-old man presented to the cardiology outpatient department with complaints of dyspnoea and palpitations (New York Heart Association Class II-III) for the last 6 months. He was evaluated with transthoracic echocardiography which showed a large mobile sac-like structure with irregular borders bulging and prolapsing into the left ventricular cavity with each cardiac cycle along with severe aortic incompetence. On transoesophageal echocardiogram, the right coronary cusp showed malcoaptation with deformed aortic sinus causing severe aortic incompetence. Cardiac computed tomography showed sparing of right coronary artery at the origin. A diagnosis of SVA was made. The patient underwent aortic valve replacement along with partial resection of the aneurysm. The patient had an uneventful postoperative course. Follow-up echocardiography after 4 weeks showed well-seated aortic valve prosthesis with residual SVA. The ejection fraction decreased from 46-48% to 36-38%.

Discussion: Comprehensive multimodality imaging can be used for management strategy of SVA.

Keywords: Aortic regurgitation; Case report; Left ventricular dysfunction; Sinus of Valsalva aneurysm; Three dimensional (3D) echocardiography.

Figure 1

Transthoracic three-dimensional apical view showing large sac-like structure (unruptured sinus of Valsalva aneurysm) occupying left ventricle cavity posteriorly.

Figure 2

(A) Transthoracic echocardiography apical four-chamber view showing moderate mitral regurgitation. (B) Transthoracic echocardiography showing narrowing of left ventricular outflow tract lumen (blue arrow) in systole by prolapsing sinus of Valsalva aneurysm. (C) Transoesophageal echocardiography showing large diastolic torrential jet from aorta filling cavities of left ventricle and sinus of Valsalva aneurysm simultaneously. (D) Transoesophageal echocardiography short-axis view 45° showing sinus of Valsalva aneurysm bulging in systole.

Figure 3

Transoesophageal echocardiography mid oesophageal level 0° view shows aneurysm sac and mitral regurgitation in the systolic frame. MV, mitral valve.

Figure 4

(A) Origin of right coronary artery. (B) Origin of sinus of Valsalva aneurysm 2 mm inferior to origin of right coronary artery. (C) Sinus of Valsalva extending into mid left ventricular cavity. (D) Sinus of Valsalva aneurysm sac in relation to interventricular septum.

Figure 5

(A) Intraoperative picture showing prolapsed right aortic cusp. (B) Post-operative echocardiogram after 1 month showing well-seated prosthetic aortic valve.