Sinus of Valsalva Aneurysm Masquerading as Coronary Artery Disease

Abstract

A 53-year-old man had recurrent angina after single coronary artery bypass grafting (left internal thoracic artery [LITA] to the left anterior descending coronary artery [LAD]). Subsequent investigations showed an aortic root mass (A) (see computed tomographic scan, Figs 1A and 1B) behind the main pulmonary artery (MPA), arising from the aortic sinus (see Fig 2; transesophageal echocardiographic, long-axis view at mid-esophageal, aortic valve level; LA = left atrium; Asc Ao = ascending aorta; LV/RV = left/right ventricle; LVOT = left ventricle outflow tract). The LITA graft was patent, but the distal run-off was small, serving a hypokinetic region.Fig 2View Large Image Figure ViewerDownload (PPT)Intraoperatively a large true Sinus of Valsalva aneurysm was identified just below the left coronary orifice (Fig 3; LCA = left coronary artery). An uneventful pericardial patch closure of the aneurysm neck was performed. As the native LAD was small and the anterior left ventricular motion was poor, the vessel was not re-grafted.Fig 3View Large Image Figure ViewerDownload (PPT)An aortogram was not performed in his pre-CABG angiography, but an unusually large gap between the LAD and circumflex arteries (Cx) was already evident (Fig 4; OM = obtuse marginal; D1 = first diagonal branch). In retrospect, the smooth but long segment stenosis on the proximal LAD and the abnormal distance from circumflex suggested the presence of a space-occupying lesion. Sinus of Valsalva aneurysm is rare and only 1% arise from the left [1Guo D.W. Cheng T.O. Lin M.L. Gu Z.Q. Aneurysm of the sinus of Valsalva: a roentgenologic study of 105 Chinese patients.Am Heart J. 1987; 114: 1169-1177Abstract Full Text PDF PubMed Scopus (52) Google Scholar]. Coronary insufficiency as a result of external compression is uncommon but should be considered in angina with unusual angiographic appearances [2Lijoi A. Parodi E. Passerone G.C. Scarano F. Caruso D. Iannetti M.V. Unruptured aneurysm of the left sinus of Valsalva causing coronary insufficiency: case report and review of the literature.Tex Heart Inst J. 2002; 29: 40-44PubMed Google Scholar].Fig 4View Large Image Figure ViewerDownload (PPT) A 53-year-old man had recurrent angina after single coronary artery bypass grafting (left internal thoracic artery [LITA] to the left anterior descending coronary artery [LAD]). Subsequent investigations showed an aortic root mass (A) (see computed tomographic scan, Figs 1A and 1B) behind the main pulmonary artery (MPA), arising from the aortic sinus (see Fig 2; transesophageal echocardiographic, long-axis view at mid-esophageal, aortic valve level; LA = left atrium; Asc Ao = ascending aorta; LV/RV = left/right ventricle; LVOT = left ventricle outflow tract). The LITA graft was patent, but the distal run-off was small, serving a hypokinetic region. Intraoperatively a large true Sinus of Valsalva aneurysm was identified just below the left coronary orifice (Fig 3; LCA = left coronary artery). An uneventful pericardial patch closure of the aneurysm neck was performed. As the native LAD was small and the anterior left ventricular motion was poor, the vessel was not re-grafted. An aortogram was not performed in his pre-CABG angiography, but an unusually large gap between the LAD and circumflex arteries (Cx) was already evident (Fig 4; OM = obtuse marginal; D1 = first diagonal branch). In retrospect, the smooth but long segment stenosis on the proximal LAD and the abnormal distance from circumflex suggested the presence of a space-occupying lesion. Sinus of Valsalva aneurysm is rare and only 1% arise from the left [1Guo D.W. Cheng T.O. Lin M.L. Gu Z.Q. Aneurysm of the sinus of Valsalva: a roentgenologic study of 105 Chinese patients.Am Heart J. 1987; 114: 1169-1177Abstract Full Text PDF PubMed Scopus (52) Google Scholar]. Coronary insufficiency as a result of external compression is uncommon but should be considered in angina with unusual angiographic appearances [2Lijoi A. Parodi E. Passerone G.C. Scarano F. Caruso D. Iannetti M.V. Unruptured aneurysm of the left sinus of Valsalva causing coronary insufficiency: case report and review of the literature.Tex Heart Inst J. 2002; 29: 40-44PubMed Google Scholar].