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IJTCVS Karbhase et al 145
2003; 19: 145–146 SOV aneurysms
Congenital aneurysms of the sinus of Valsalva are
rare lesions. These can rupture into any cardiac chamber,
depending upon the site of origin of the aneurysm,
forming aortocardiac fistulas. We encountered a 30-year-
old male, with aneurysm of the right sinus of Valsalva,
which through the infundibulum, projected into the
pulmonary artery, and presented with right ventricular
outflow tract obstruction ( RVOTO)
Case Report
Congenital aneurysms of the sinus of Valsalva are
rare lesions. These aneurysms follow predictable
intracardiac course, usually rupturing into adjacent low-
pressure chamber. Patients present either with
aortocardiac fistulas with large shunts and congestive
cardiac failure or with signs of ventricular septal defect
(VSD) and /or aortic incompetence (A1). It is extremely
rare for an aneurysm to rupture into the pulmonary
artery or to project into the pulmonary artery to cause
right ventricular outflow tract obstruction.
We encountered a 30-year-old male, who presented
with dyspnea on exertion (NYHA class II) and
palpitations. Clinical examination revealed signs of right
ventricular overload. A grade 1V/V1 systolic murmur
was found in the left parasternal area in the 2nd and 3rd
interspaces. Echocardiography revealed obstruction to
the right ventricular outflow tract at the valvar level.
There was no VSD or AI.
The patient was posted for cardiac catheterization
and possible balloon dilatation of the RVOTO, however
on cardiac catheterization a 4 cm large aneurysm arising
from the right sinus of Valsalva was found obstructing
the pulmonary artery at the level of the valve annulus.
Unruptured aneurysms of the sinus of valsalva into the
pulmonary artery presenting with right ventricular outflow
tract obstruction
JN Karbhase, M.Ch, P Sinha, MS, P Joshi, M.Ch, C Doshi, MS, KN Nagle, M.Ch.
BYL Nair Charitable Hospital, Dept. of CTVS, Mumbai
The patient underwent an elective operation.
Through a median sternotomy ascending aortic and
bicaval cannulation was done and cardiopulmonary
bypass started. A vent was placed through the right
superior pulmonary vein. Aorta was cross-clamped and
a transverse aortotomy was made. Warm sanguinous
direct intracoronary cadioplegic infusion was used to
arrest the heart. The aneurysm found to be arising form
the right sinus of Valsalva, and was projecting through
the infundibulum into the pulmonary artery. Aneurysm
Address for correspondence:
Dr. J.N. Karbhase
Prof. & Head, CTVS, 2nd Floor, College Building
BYL Nair Charitable Hospital, Mumbai – 08
email –dr-pranavas@yahoo.com
©IJTCVS 097091341931103/003
Fig. 2. Right ventriculogram showing filling deffect in outflow tract.
Fig. 1. Left ventriculogram showing opacification of the aneurysm.
Case reports
030-02.p65 8/24/2003, 12:40 PM145
146 Karbhase et al IJTCVS
SOV aneurysms 2003; 19: 145–146
sac was everted excised and the defect repaired with a
PTFE patch. The aorta was closed. The patient was
weaned off cardiopulmonary bypass. The postoperative
recovery was uneventful. The postoperative
echocardiogram showed no residual RVOTO. There was
no residual AI.
Comment
Congenital aneurysms of the sinus of Valsalva are
extremely rare lesions with an incidence of 0.1%1. they
are almost five times more common in Asians2. Three
quarters of the patients are males4.
Two thirds of the aneurysms arise from the right
aortic sinus, one quarter from the noncoronary sinus
and remaining from the left aortic sinus1.
Associated lesions are common in congenital sinus
of Valsalva aneurysm1. Aortic imcompetence occurs in
almost 30% to 75% of cases and ventricular septal defects
occur in 30% to 50% of cases3. The aneurysm usually
follows a predictable intracardiac course4. Owing to the
central nature of the aortic root they can rupture into
any cardiac chamber. However rupture into the
pulmonary artery or the pericardium is rare1. The
incidence of rupture into the pulmonary artery is less
than 1%1, and there is only one case report so far5. This
is because of the anatomical relationship of the aortic
root to the pulmonary artery, the pulmonary artery being
separated from the aorta by the infundibulum. Another
report of an unruptured sinus of Valsalva into the
pulmonary artery has been made4.
There was no residual RVOTO following successful
surgical repair of the lesion. There is 17% risk of
development of late AI requiring aortic valve
replacement3, hence such patients must be kept in close
long-term observation.
References
1. Kirklin JW, Barratt Boyes BE. Congenital aneurysms of the sinus
of Valsalva In: Kirklin JW, Barratt Boyes BE, eds, Cardiac surgery.
2nd ed. New York: Churchill Livingstone, 1993; 825–39.
2. Chu Sh, Hung CR, How SS, et al. Ruptured aneurysms of the
sinus of Valsalva in Oriental patients. J Thorac Cardiovas Surg.
1990; 99: 288–98.
3. Azakie A, David TE, Peniston CM, et al. Ruptured sinus of
Valsalva aneurysm: Early recurrence and fate of the aortic valve.
Ann Thorac Surg. 2000; 70: 1466–71.
4. Shiraishi S, Watarida S, Katsuyama K, et al. Unruptured
aneurysm of the sinus of Valsalva into the Pulmonary artery.
Ann Thorac Surg. 1998; 65: 1458–59.
5. Heilman KJ, Groves BM, Cammpbell D, et al. Rupture of left
sinus of Valsalva aneurysm into the pulmonary artery. J Am Coll
Cardiol. 1985; 5: 1005–07.
Fig. 3. Right ventriculogram showing outflow tract obstruction.
030-02.p65 8/24/2003, 12:40 PM146
