Indian Heart J 2005; 57: 343–345 Manocha et al. Septal Dissection by ASOV Rupture 343

Aneurysm of Sinus of Valsalva Dissecting intoInterventricular Septum with Left Ventricular

Communication

S Manocha, NS Chouhan, S Mittal, AK Omar, Ravi R KasliwalDepartment of Non-invasive Cardiology, Escorts Heart Institute and Research Centre, New Delhi

Brief Report

Septal dissection with left ventricular communication is a rare complication of aneurysm of sinus of Valsalva.This report describes a case of aneurysm of sinus of Valsalva with septal dissection, almost in its entirety withleft ventricular communication – which is a very rare occurrence. (Indian Heart J 2005; 57: 343–345)

Key Words: Sinus of Valsalva aneurysm, Septal dissection, Echocardiography

Correspondence: Dr Ravi R Kasliwal, Director, Department of Non-invasive Cardiology, Escorts Heart Institute and Research CentreNew Delhi 110025. e-mail: rrkasliwal@hotmail.com

Aneurysms of sinus of Valsalva (ASOV) are rare andaccount for only 1% of congenital cardiac anomalies

with slightly higher incidence in Asian subcontinent. Septaldissection is an extremely rare complication and leftventricular communication is even rarer and to-date, onlyeight such cases have been reported.1,2

Case Report

A 33-year-old gentleman with no history of hypertension,diabetes mellitus or rheumatic heart disease presented withhistory of sudden onset retrosternal chest pain along withdizziness on standing lasting for 15-20 min, 3 days prior toadmission. General physical examination revealedtachycardia (pulse rate 106 beats/min) with wide pulsepressure (blood pressure 146/56 mmHg in right arm, insupine posture). The pulse was high volume, normal incharacter and all peripheral pulses were well palpable.Precordial examination revealed grade III/VI to and fromurmur all over the precordium. Twelve-lead surfaceelectrocardiogram (ECG) and 24-hour Holter monitoringdid not reveal any atrioventricular conduction disturbance.

Two-dimensional transthoracic and transesophagealechocardiography (TTE and TEE) revealed large aneurysmof sinus of Valsalva of right coronary cusp burrowing intothe interventricular septum (IVS) (Fig. 1) causing septaldissection, almost in its entirety with a small perforation

toward apical margin of the septal dissection resulting in acommunication with the left ventricular cavity (Figs 2 and3). There was significant to and fro flow into the sinus ofValsalva aneurysm (Figs 4 and 5). Mild aortic regurgitationwas also present.

The findings were confirmed intra-operatively. The defectwas repaired by Dacron patch closure of mouth ofaneurysm and subsequently the cavity became thrombosed(Fig. 6). Post-operatively, the patient had an uneventfulrecovery and was discharged on post-operative day 8.The patient was asymptomatic on his last follow-up at30 days.

Fig. 1. 2D echo (Plax view) demonstrating aneurysm of sinus of Valsalvadissecting into septum. The arrow shows the entry point of septal dissection.2D echo: two-dimensional echocardiography; LA: left atrium; LV: leftventricle; An: aneurysm of sinus of Valsalva

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344 Manocha et al. Septal Dissection by ASOV Rupture Indian Heart J 2005; 57: 343–345

Discussion

Aneurysms of sinus of Valsalva account for only 1% ofcongenital cardiac anomalies. Out of these aneurysms,70% arise from right sinus of Valsalva, 25% from non-coronary sinus and only < 5% from the left coronary sinus.1

Most common complications resulting from ASOV includeaortic regurgitation, coronary artery flow compromise,atrioventricular conduction blocks, endocarditis and mostimportantly, rupture into cardiac chambers.2-4 Rupturemost commonly occurs into right ventricle (60%-90%) andless commonly into right atrium (10%), left atrium (3%),pericardium and ventricular septum (<1%).5 Rupture of

Fig. 2. 2D echo (Plax view) demonstrating the left ventricular communicationtoward apical margin of dissected septum.Ao: aorta; An: aneurysm of sinus of Valsalva; LV: left ventricle, LA: leftatrium

Fig. 3. Transesophagal echo (transgastric short axis view) showing rent in theseptum responsible for communication between aneurysm and left ventricle.An: aneurysm of sinus of Valsalva; LV: left ventricle

Fig. 4. Transesophageal color Doppler (long axis view) showing blood flow fromseptal dissection to ascending aorta in systole.Ao: aorta; LVOT: left ventricular outflow tract; An: aneurysm

Fig. 5. Transesophageal color Doppler view is showing blood flow into septaldissection from ascending aorta in diastole.Ao: aorta; LV: left ventricle; LA: left atrium; An: aneurysm of sinus ofValsalva; IVS: interventricular septum; RV: right ventricle

ASOV into IVS is exceedingly rare. This rare condition ofrupture of ASOV into IVS mostly involves right coronarysinus with further communication into one or both of theventricles, with significant aortic regurgitation, congestiveheart failure and conduction disturbance. In the presentcase also, ASOV originated from right coronary sinus,dissected into IVS and finally opened into left ventriclethrough a small perforation in the IVS. To our knowledge,only eight such cases have been so far reported in theliterature. However, this is the only case in whichtransthoracic, transesophageal and post-operativeechocardiography images have been demonstrated.

Echocardiographic picture in such cases is diagnostic in

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Indian Heart J 2005; 57: 343–345 Manocha et al. Septal Dissection by ASOV Rupture 345

Fig. 6. 2D echo (Plax view) during post-operative period showing patch repairof aneurysm and thrombosed septum.

most instances. Demonstration of the cavity within IVS,communicating with both aneurysmally dilated sinus ofValsalva as well as left ventricle is virtually pathognomonicof the disease entity. Traumatic dissection of IVS, congenitalaneurysm of IVS and necrosis within intra-septal tumor

may present with a cavity within IVS. However, absence ofASOV and communication of the cavity with it willdifferentiate these entities from the former one. On the otherhand, aorta to left ventricular tunnel presents with acommunication between aortic root and left ventricle butin this condition, there is no cavity within IVS. Thus, anaccurate diagnosis of ASOV rupture into IVS with leftventricular communication can be made on the basis ofTTE and TEE to guide successful surgical repair.

References

1. Wells T, Byrd B, Neirste D, Fleurelus C. Sinus of Valsalva aneurysmwith rupture into the interventricular septum and left ventricularcavity. Circulation 1999; 100: 1843–1844

2. Choudhary SK, Bhan A, Reddy SC, Sharma R, Murari V, Airan B, etal. Aneurysm of sinus of Valsalva dissecting into interventricularseptum. Ann Thorac Surg 1998; 65: 735–740

3. Choudhary SK, Airan B, Venugopal P. Dissecting aneurysm of theinterventricular septum. Eur J Cardiothorac Surg 2003; 23: 650–651

4. Wu Q, Xu J, Shen X, Wang D, Wang S. Surgical treatment of dissectinganeurysm of the interventricular septum. Eur J Cardiothorac Surg2002; 22: 517–520

5. Prian GW, Dieltrich EB. Sinus of Valsalva abnormalities: a specificdifferentiation between aneurysm of and aneurysm involving thesinus of Valsalva. Vasc Surg 1973; 7: 155–164

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