Rupture of the sinus of valsalva aneurysm presenting with a predominantly diastolic murmur without continuous murmur

Excerpt

A 20 year-old man presented to our hospital with the sudden onset of persistent epigastric pain and palpitations that began 2 weeks prior. His blood pressures was 123/39 mmHg. Auscultation revealed a to-and-fro murmur, predominantly diastolic, with a Levine grade V/VI and a thrill, most prominent at the 3 left sternal border (Fig. 1a). Electrocardiogram revealed left atrial enlargement and an incomplete right bundle branch block. Two-dimensional transthoracic echocardiography (2D-TTE) demonstrated a preserved left ventricular ejection fraction and mild biventricular enlargement. Additionally, 2D-TTE and three-dimensional transesophageal echocardiography (3D-TEE) revealed increased shunt flow between the non-coronary sinus of Valsalva and the right atrium during diastole (Fig. 1b, 1b’, and Supplementary Video 1), leading to the diagnosis of a type IV rupture of the sinus of Valsalva aneurysm (RSoVA). Doppler echocardiography confirmed that the shunt flow began during diastole (Fig. 1c). Multi-view of 3D-TEE exhibited a defect that opened during diastole (Fig. 1d, 1d’) and narrowed during systole (Fig. 1e, e’). The defect was 10 mm long and 8 mm wide. The size of the aortic annulus was 22 mm, the sinus of Valsalva was 28 mm, and the sinotubular junction was 26 mm. The murmur remained unchanged from admission to surgery. The patient underwent a surgical double-patch closure, resulting in the disappearance of shunt flow and resolution of subjective symptoms.

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