Rupture of the sinus of Valsalva: A Study of eight cases with discussion on the differential diagnosis of continuous murmurs

Abstract

Rupture of the sinus of Valsalva presents a characteristic clinical picture which can be recognized using the usual clinical methods and be proved by right heart catheterization and aortic root cineangiography. The lesion caused 8 of 49 consecutive continuous murmurs observed in patients over 14 years of age studied at this Cardiovascular Unit. There was nothing distinctive about the symptoms to suggest the diagnosis. Seven of these eight patients had congestive failure following rupture. Chest pain on rupture, which probably occurs in less than half of all cases, was seen in none of these 8. One developed the pain of acute hepatic congestion. Three had had subacute bacterial endocarditis. The physical findings, however, suggested the diagnosis in all cases. Characteristically, a continuous murmur developed in the patient who previously had no murmurs or only a systolic murmur. It was maximal along the left sternal border at the third and fourth left interspaces; the diastolic element in some instances could be heard to the right of the sternum. Signs of rapid aortic run-off were usually present. A high pulmonary arterial pressure was reflected in a loud pulmonary second sound. The left to right shunt caused a mitral mid-diastolic murmur in 2 patients. A left parasternal heave was frequently felt on palpation, reflecting the increase in right ventricular stroke volume and pressure caused by the fistula. The electrocardiograms did not aid in the diagnosis although four showed RSR' deflections in lead V 1. The roentgenograms were helpful. Enlargement of the right atrium and right ventricle was present in all cases and was most easily recognized when a roentgenogram taken before rupture was available for comparison. In most of them, the pulmonary arteries were enlarged. On fluoroscopy, increased pulmonary vascular pulsation was usually but not always present. Right heart catheterization and retrograde aortic root angiography through the femoral artery, followed by left ventricular angiography, proved to be a reliable means of recognizing the lesion, as well as any associated congenital or acquired defects (e.g. ventricular septal defect, aortic insufficiency, or pulmonary stenosis). Recognition of patients with this lesion is important because even when congestive failure is present, they can be restored to good health by successful surgery.