Imaging a Large Unsuspected Sinus of Valsalva Aneurysm Dissecting into the Interventricular Septum

Abstract

A previously healthy 35-year-old man was transferred to our intensive care unit with severe dyspnea, hypotension, and a history of atypical chest pain. The patient’s clinical condition appeared to be rapidly deteriorating, showing signs cerebral hypoperfusion, in that he was somnolent yet responsive on presentation. Pulmonary inspiratory rales were heard over all lung areas of auscultation and harsh continuous murmurs were heard over the precordium. His systemic blood pressure was low (80/40 mm Hg) and his heart rate was elevated (100 bpm with sinus rhythm). His medical and clinical history revealed no infection, cardiac disease, or chest trauma. Because the clinical signs and hemogasanalysis were indicative of imminent sudden respiratory failure, tracheal intubation was preformed. Transesophageal echocardiography (TEE), as opposed to transthoracic echocardiography, was then performed, which provides high-resolution images, multiple scan planes, and an accurate assessment of cardiac and aortic pathology. A midesophageal four-chamber TEE view at 0 degrees rotation showed a moderately depressed left ventricular function (ejection fraction of about 40%) and what appeared to be a third anomalous chamber between the right and left ventricle (Fig. 1 top left). A midesophageal aortic valve (AV) long axis view showed a pulsating aneurysmal outpouching off of the aortic root (5 cm 10.5 cm) that completely dissected the interventricular septum (Fig. 1 top right). The aortic insufficiency appeared to be secondary to structural abnormality of the right coronary cusp, possibly secondary to decreased support of the cusp as a result of the location of the sinus of valsalva aneurysm (SVA) (Video clips 1 and 2; please see video clips available at www.anesthesia-analgesia.org). This brisk bidirectional flow finding was interpreted as a SVA originating from the right coronary cusp and extending through the entire interventricular septum. Given its large size and extension to the interventricular septum, it was unclear from TEE findings whether the aneurysm had ruptured. Advancing the probe to the transgastric mid short axis view at 0 degrees rotation showed that the right ventricle was small and flattened (Fig. 1 bottom). It appeared that the cause of hypotension was probably the inflow/outflow obstruction of the right ventricle from the SVA (Video clips 1 and 2). Cardiac catheterization confirmed a normal coronary artery tree and the presence of the SVA originating from the right sinus (Video clips 1 and 2). The patient was prepared and underwent emergency surgery, at which time intraoperative TEE confirmed our preoperative findings. It is clear that TEE in this case allowed for accurate detection of an unexpected severe abnormality, altering diagnosis and surgical strategy. During surgery, aortotomy revealed that the aneurysm orifice (2.5 cm 1.5 cm) was located in the right coronary sinus (Fig. 2). The AV appeared to be tricuspid, with a right hypoplastic coronary cup and an abnormal noncoronary redundant flap located at the base of the aortic annulus. A considerable amount of bio-glue was injected in the aneurysm orifice, which was then sealed with a composite Dacron patch of autologous pericardium tissue. The AV was also replaced with a St. Jude 21 mm mechanical bi-leaflet prosthesis valve. The patient was weaned from cardiopulmonary bypass and TEE confirmed good surgical results. The patient had an uneventful postoperative course with cardiac function recovery. This article has supplementary material on the Web site: www.anesthesia-analgesia.org.