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Severe aortic insufficiency in a patient with sinus of Valsalva aneurysm invading the interventricular septum
  1. G V Moukarbel,
  2. A B Abchee

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A 27 year old man presented with a history of dyspnoea on exertion that progressed to dyspnoea at rest. ECG showed left bundle branch block and first degree atrioventricular block. Physical examination revealed a holodiastolic rumble at the left sternal border. A transthoracic echocardiogram showed an enlarged left ventricle with severe aortic regurgitation. A cystic lesion in the base of the septum, communicating with the left ventricular outflow tract, was noted. The patient underwent aortic valve replacement. Intraoperative transoesophageal echocardiography and findings at surgery were consistent with a sinus of Valsalva aneurysm, destroying the aortic valve and dissecting into the interventricular septum. The patient is doing well on follow up three years later.

Sinus of Valsalva aneurysms are rare, occurring in 0.14–0.96% of patients undergoing open heart surgery. Aneurysms dissecting into the interventricular septum are even less frequent, with only about 50 cases described in the English literature. Complications include infective endocarditis, atrioventricular conduction abnormalities, and aortic regurgitation with varying degrees of severity, most likely due to lack of anatomical support of the aortic leaflet. This report demonstrates the transthoracic and transoesophageal echocardiographic two dimensional and colour Doppler findings of a sinus of Valsalva aneurysm with dissection into the interventricular septum and severe aortic regurgitation, illustrating the loss of anatomical support of the leaflet causing valvar incompetence.

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Transthoracic parasternal (A) and apical (B) views showing the aneurysm eroding into the basal septum. Transoesophageal long axis view without (C) and with (D) colour Doppler imaging showing severe aortic regurgitation with the regurgitant flow filling the aneurysm. Yellow arrows in (A) and (C) point to the disrupted aortic leaflet. Ao, aorta; LV, left ventricle; RV, right ventricle; SVA, sinus of Valsalva aneurysm.