Ruptured sinus of Valsalva aneurysm: diagnosis by community echocardiography

Summary

A 71-year-old man was referred to a general practitioner with specialist interest (GPSI) in cardiology due to exertional breathlessness. Examination revealed a continuous murmur but no signs of heart failure. Echocardiography revealed significant aortic root enlargement (63 mm) with aneurysmal dilatation of the right sinus of Valsalva (Fig. 1A, Video 1) and severe aortic regurgitation (Fig. 1B). Parasternal short-axis images suggested rupture of the aneurysmal right aortic sinus (Fig. 1C, Video 2) with colour Doppler imaging suggestive of a shunt from the aorta into the right atrium (Fig. 1D, Video 3). The study was uploaded to a cloud-based server (Ultralinq Healthcare Solution Inc, New York, USA) and the GPSI contacted the local tertiary centre urgently. On image review, the suspicion was confirmed of an aorto-atrial fistula secondary to the ruptured sinus of Valsalva aneurysm and the patient was hospitalized the same day. At surgery, the aortic root had significantly thinned walls in all sinuses with the presence of a large aneurysm extending from the right coronary sinus towards the right ventricular outflow tract. The fistulous communication was identified and led into the right atrium — this was repaired with pledgeted sutures. A modified Bentall procedure was performed, with a 27 mm Perimount, bioprosthesis sewn into a 34 mm Valsalva Gelweave graft for the aortic root replacement. Sinus of Valsalva aneurysm is a rare abnormality (population incidence 0.09%) that occurs due to a weakening of the layers of the aortic wall (principally the aortic media). This may be due to a congenital abnormality in the aortic wall or may be acquired following bacterial endocarditis or connective tissue disorders. Most aneurysms arise from the right coronary sinus and at least 1/3 will rupture. Rupture into the right heart chambers can lead to a significant intra-cardiac shunt and acute heart failure. In recent years, there has been a significant expansion of community cardiology clinics, including the provision of echocardiography. The method of storage of echocardiographic studies is variable — this case highlights not just the potential value of skilled community echocardiography operators but also the value of cloudbased servers that can facilitate rapid expert review of images performed remotely so that timely management decisions can be made.