Prof.C.Amarnath, Dr.G.Sathyan, Dr.R.Ganga Devi, Dr.D.Kanimozhi

ABSTRACT BACKGROUND: Sinus of Valsalva are three subtle dilatations of the aortic root wall that arise between the aortic valve annulus and the sinotubular ridge. Each sinus is associated with a corresponding right, left or noncoronary aortic valve cusp. Aneurysm of sinus of Valsalva is rare accounting for 0.14 % (2). Aneurysm are most common in right coronary sinus (70–90%), followed by non coronary sinus(10–20%), left coronary sinus(<5%) (2). CASE REPORT: We present a 31 year old female with complaints of pain abdomen, on investigation- CT abdomen showed abnormality of aortic root, which in further investigation proved to be unruptured aneirysms from the left sinus of Valsalva. The aneurysms extended into the interatrial septum with a thrombus within it, other into the groove between the aorta and left atrium, third dissected into the anterolateral left ventricular wall.

UNRUPTURED MULTICOMPARTMENTAL LEFT SINUS OF VALSALVA ANEURYSM 2D-ECHO - Aneurysm component in the groove between aorta and left atrium - Interatrial septal component of aneurysm with thrombus LA- left atrium, RA- right atrium, LV-left ventricle, RV- right ventricle, LVOT- left ventricular outflow tract. LV LVOT LA RV RA LV RV LA * Parasternal view 4-chamber view Prof.C.Amarnath, Dr.G.Sathyan, Dr.R.Ganga Devi, Dr.D.Kanimozhi

UNRUPTURED MULTICOMPARTMENTAL LEFT SINUS OF VALSALVA ANEURYSM 2D-ECHO LV SVA LA RV RA LV RV LA - Aneurysm component dissecting into in the left ventricular wall - Interatrial septal component of aneurysm with thrombus LA- left atrium, RA- right atrium, LV-left ventricle, RV-right ventricle. * 4-chamber view * * Prof.C.Amarnath, Dr.G.Sathyan, Dr.R.Ganga Devi, Dr.D.Kanimozhi

CT ANGIO UNRUPTURED MULTICOMPARTMENTAL LEFT SINUS OF VALSALVA ANEURYSM RA SVA LCA AO RA- right atrium, AO-aorta, PA-pulmonary artery, SVC-superior vena cava, LCA-Left coronary artery, SVA-Sinus of Valsalva Aneurysm from left aortic sinus. PA SVC Prof.C.Amarnath, Dr.G.Sathyan, Dr.R.Ganga Devi, Dr.D.Kanimozhi

AO SVA AO SVA PULM VEINS LA LEFT SINUS OF VALSALVA ANEURYSM DISSECTING INTO THE ANTEROLATERAL WALL OF THE LEFT VENTRICLE. LEFT SINUS OF VALSALVA ANEURYSM DISSECTING INTO GROOVE BETWEEN AORTA AND LEFT ATRIUM LA- left atrium, RA- right atrium, LV-left ventricle, RV-right ventricle, AO-Aorta, SVA-Sinus of Valsalva Aneurysm from the left aortic sinus. Prof.C.Amarnath, Dr.G.Sathyan, Dr.R.Ganga Devi, Dr.D.Kanimozhi CT ANGIO

SVA LVOT SVA LA LEFT SINUS OF VALSALVA ANEURYSM DISSECTING INTO THE ANTEROLATERAL WALL OF THE LEFT VENTRICLE. LEFT SINUS OF VALSALVA ANEURYSM DISSECTING INTO INTERATRIAL SEPTUM LV LA RA LVOT RV LA- left atrium, RA- right atrium, LV-left ventricle, RV-right ventricle, LVOT- left ventricular outflow tract, SVA-Sinus of Valsalva Aneurysm. Prof.C.Amarnath, Dr.G.Sathyan, Dr.R.Ganga Devi, Dr.D.Kanimozhi CT ANGIO

SVA LA LEFT SINUS OF VALSALVA ANEURYSM DISSECTING INTO THE ANTEROLATERAL WALL OF THE LEFT VENTRICLE. LEFT SINUS OF VALSALVA ANEURYSM DISSECTING INTO INTERATRIAL SEPTUM WITH THROMBUS LV LA RA LV RV LA- left atrium, RA- right atrium, LV-left ventricle, RV-right ventricle, SVA-Sinus of Valsalva Aneurysm. Prof.C.Amarnath, Dr.G.Sathyan, Dr.R.Ganga Devi, Dr.D.Kanimozhi CT ANGIO

SVA LCA AO LEFT SINUS OF VALSALVA ANEURYSM DISSECTING INTO THE ANTEROLATERAL WALL OF THE LEFT VENTRICLE. LEFT SINUS OF VALSALVA ANEURYSM DISSECTING INTO INTERATRIAL SEPTUM WITH THROMBUS LV LA RA LVOT PUL ART LA- left atrium, RA- right atrium, LV-left ventricle, RV-right ventricle, SVA-Sinus of Valsalva Aneurysm, PUL ART- pulmonary artery, LCA-Left coronary artery, AO-Aorta. CURVED MPR

DISCUSSION: Sinus of Valsalva are three subtle dilatations of the aortic root wall that arise between the aortic valve annulus and the sinotubular ridge. Each sinus is associated with a corresponding right, left or noncoronary aortic valve cusp. Left and right truncoconal swellings develop along the inferior end of the truncus arteriosus during the 5th week of embryogenesis, just before septation of the truncus into anterior pulmonary and posterior aortic channels. After septation, each ventricular outflow tract contains three tubercles, which later form the cusps of the aortic valve and the main pulmonary artery. During the 5th and 6th weeks of embryogenesis, the Valsalva sinuses and aortic valve leaflets begin to form. The right and left main coronary arteries bud simultaneously from their respective developing sinuses. By the 9th week, formation of the aortic valve leaflets and Valsalva sinuses generally is complete. UNRUPTURED MULTICOMPARTMENTAL LEFT SINUS OF VALSALVA ANEURYSM Prof.C.Amarnath, Dr.G.Sathyan, Dr.R.Ganga Devi, Dr.D.Kanimozhi

A. Three-dimensional arrangement of the aortic root, which contains 3 circular “rings,” but with the leaflets suspended within the root in crown-like fashion B. The leaflets have been removed from this specimen of the aortic root, showing the location of the 3 rings relative to the crown-like hinges of the leaflets. VA indicates ventriculoarterial; A-M, aortic-mitral. Diagrammatic representation of sinus of Valsalva illustrates relationship with adjacent cardiac chambers and most frequent sites of rupture. RA = right atrium, RVOT = right ventricular outflow tract, LA = left atrium, LAA = left atrial appendage, R = right coronary cusp, L = left coronary cusp, NC = noncoronary cusp.

Aneurysms of the Valsalva sinus (aortic sinus) can be congenital or acquired. Congenital aneurysms may result from localized weakness of the elastic lamina or an underlying deficiency of normal elastic tissue. Acquired aneurysms commonly are caused by infectious diseases such as bacterial endocarditis, syphilis, and tuberculosis; degenerative conditions such as atherosclerosis and cystic medial necrosis; and injury from deceleration trauma. They are more common among men than women and among Asians. Non-ruptured aneurysms may be asymptomatic and incidentally discovered, or they may be symptomatic and manifest acutely with mass effect on adjacent cardiac structures. Ruptured Valsalva sinus aneurysms result in an aortocardiac shunt and may manifest as insidiously progressive congestive heart failure, severe acute chest pain with dyspnea, or, in extreme cases, cardiac arrest. Although both ruptured and nonruptured Valsalva sinus aneurysms may have potentially fatal complications, after treatment the prognosis is excellent. UNRUPTURED MULTICOMPARTMENTAL LEFT SINUS OF VALSALVA ANEURYSM Prof.C.Amarnath, Dr.G.Sathyan, Dr.R.Ganga Devi, Dr.D.Kanimozhi

Most Valsalva sinus aneurysms are seen at echocardiography, but both ECG gated CT and MR imaging can provide excellent depiction of the relevant anatomy, and MR imaging can provide valuable functional information. TREATMENT : Medical management usually involves stabilization and perioperative assessment and management. Transcatheter closure of ruptured sinus of Valsalva aneurysm (SVA) has been successfully performed using Amplatzer devices. Although advanced percutaneous techniques have been performed in the correction of this anomaly, open-heart surgery with or without aortic valve replacement remains the treatment of choice, with an operative mortality rate of less than 2%. Urgent surgical repair in all patients with ruptured SVA and unruptured SVA is often recommended because of its association with increased morbidity and mortality. UNRUPTURED MULTICOMPARTMENTAL LEFT SINUS OF VALSALVA ANEURYSM Prof.C.Amarnath, Dr.G.Sathyan, Dr.R.Ganga Devi, Dr.D.Kanimozhi

REFERENCES

ACKNOWLEDGEMENTS PROF C AMARNATH, H.O.D (STANLEY MEDICAL COLLEGE) DR G SATHYAN, ASSO. PROF DR K SIVASANKAR, DR B SUHASINI, DR R GANGA DEVI, DR SUDHAKAR- ASST. PROFS