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Sinus of Valsalva aneurysm rupture into the left atrium
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A 65 year old woman underwent routine transthoracic echocardiography for assessment following repeat left atrial myxoma excision 12 years after first recurrence. The transthoracic echo revealed a shunt between the left atrium and aorta. This lesion was further assessed with a transoesophageal echo which confirmed a coronary sinus fistula into the left atrium without dilatation of the sinus itself. There was no evidence of any other abnormality associated with aneurysms of the sinus of Valsalva. The aortic leaflets were normal with no aortic regurgitation. The left atrium was mildly dilated, there was trivial mitral regurgitation, and left ventricular function was unimpaired. She remains very well with no signs of left ventricular dysfunction and a normal exercise tolerance.

Aneurysms of the sinus of Valsalva, also known as coronary sinus fistula, are rare and usually rupture into the right chambers of the heart. they arise from thenon-coronary sinus in about 25% of cases and rupture more frequently into the right ventricle or right atrium. However, perforation may occur into the left ventricle, interventricular septum, pulmonary artery, superior vena cava, pleura or pericardium. There is a male predominance and an association with ventricular septal defect, aortic regurgitation, pulmonary stenosis, and membranous subaortic stenosis.

Most aneurysms are thought to be congenital in origin, arising because of the discontinuity between aortic tunica media and aortic valve annulus. The occurrence of the sinus of Valsalva aneurysm may well have been coincidental, rather than caused by the two procedures for atrial myxoma excision.