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A 39 year old woman was admitted to hospital for investigation and management of a febrile illness of six weeks' duration. She was haemodynamically stable but a grade 4/6 continuous murmur, best heard at the left sternal edge, was noted. A diagnosis of bacterial endocarditis was made after blood cultures grew viridans streptococci. Treatment with intravenous penicillin and gentamicin was begun.
A communication between the right aortic sinus of Valsalva and the right atrium (RA) was seen on transoesophageal colour Doppler echocardiography (right, arrow). No vegetations were identified. A significant left to right shunt (Qp:Qs 2:1) was evident at cardiac catheterisation. Left ventriculography confirmed the presence of an aortico-atrial communication, with contrast filling the right heart. At surgery a 15 mm defect in the right aortic sinus was noted, communicating with the right atrium and associated with vegetations. There was no aneurysmal dilatation of the sinuses of Valsalva. The defect was closed with a Goretex patch, but in order to obliterate the communication effectively, it was necessary to replace the aortic valve with a prosthetic valve. The patient made an uneventful recovery.
Rupture of an aortic sinus of Valsalva aneurysm into an adjacent cardiac chamber is a well recognised, albeit uncommon, condition. In contrast, rupture of an aortic sinus in the context of bacterial endocarditis without a pre-existing aneurysm is a rare occurrence. In the clinical setting of bacterial endocarditis and no valvar vegetations on echocardiography, a high index of suspicion is required to allow early diagnosis of this condition and referral for cardiac surgery as indicated.