- Email: [email protected]
A large aneurysm of a left sinus of Valsalva invading the interventricular septum – a rare cause of syncope
&$6(5(3257
$ODUJHDQHXU\VPRIDOHIWVLQXVRI9DOVDOYDLQYDGLQJ WKHLQWHUYHQWULFXODUVHSWXP²DUDUHFDXVHRIV\QFRSH 0XVWDSKD(O+DWWDRXL0'1DGLD&KDUHL0''ULVVL%RXP]HEUD0'6DLG&KUDLEL0'$KPHG%HQQLV0'
0(O+DWWDRXL1&KDUHL'%RXP]HEUD6&KUDLEL$%HQQLV$ ODUJH DQHXU\VP RI D OHIW VLQXV RI 9DOVDOYD LQYDGLQJ WKH LQWHUYHQWULFXODU VHSWXP q D UDUH FDXVH RI V\QFRSH &DQ - &DUGLRO HH
8QODUJHDQÑYULVPHGXVLQXVGH9DOVDOYD JDXFKHTXLHQYDKLWOHVHSWXPLQWHUYHQWULFXODLUH 8QHUDUHFDXVHGHV\QFRSH
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
/HVDQÑYULVPHVGXVLQXVGH9DOVDOYDVRQWUDUHVQRWDPPHQWFHX[GXVLQXV GH 9DOVDOYD JDXFKH (VW SUÑVHQWÑ OH FDV G XQH IHPPH GH DQV TXL D FRQVXOWÑ Í FDXVH G XQH V\QFRSH (OOH VRXIIUDLW G XQ EORFDJH FDUGLDTXH FRPSOHW / DXVFXOWDWLRQ D UÑYÑOÑ XQH UÑJXUJLWDWLRQ DRUWLTXH PRGÑUÑH / ÑFKRFDUGLRJUDSKLH WUDQVWKRUDFLTXH D UÑYÑOÑ TXH OD PHPEUDQH VRXV DRUWLTXH ÑWDLW OLÑH DX VHSWXP LQWHUYHQWULFXODLUH DYHF H[SDQVLRQ GH OD GLDVWROH HW FROODSVXV GH OD V\VWROH 2Q D FRQVWDWÑ XQ IOX[ GLDVWROLTXH HQ ERUGXUH GH FHWWH PHPEUDQH / ÑFKRFDUGLRJUDSKLH WUDQVVRSKDJLHQQH D UÑYÑOÑ XQH PDVVH N\VWLTXH TX RQ SHQVDLW ÒWUH XQ ODUJH DQÑYULVPH DYHF WKURPEXV SDULÑWDO GX VLQXV FRURQDLUH JDXFKH V ÑWHQGDQW GDQV OH VLQXV LQWHUYHQWULFXODLUH / LPDJHULH SDU UÑVRQDQFH PDJQÑWLTXH D FRQILUPÑ OH GLDJQRVWLF / H[SDQVLRQ GH O DQÑYULVPH DX VHSWXP LQWHUYHQWULFXODLUH D SURYRTXÑXQEORFDJHFDUGLDTXHFRPSOHWSUREDEOHPHQWSDUFRPSUHVVLRQGH ODIRQFWLRQQRUPDOHGXQXGDXULFXORYHQWULFXODLUH/HVUDSSRUWVGHFDVGH FHWWHDVVRFLDWLRQVRQWG XQHH[WUÒPHUDUHWÑ/HSUÑVHQWDUWLFOHHVWO XQGHV UDUHVUDSSRUWVGÑFULYDQWO DSSDULWLRQG XQDQÑYULVPHGXVLQXVGH9DOVDOYD JDXFKHÍO LPDJHULHSDUUÑVRQDQFHPDJQÑWLTXH
.H\:RUGV $QHXU\VP +HDUWEORFN ,PDJLQJ 6\QFRSH 9DOVDOYD
LQXVRI9DOVDOYDDQHXU\VPVUHPDLQXQFRPPRQDOWKRXJKWKHUDWH RI GLVFRYHU\ KDV LQFUHDVHG ZLWK WKH ZLGHVSUHDG DYDLODELOLW\ RI HFKRFDUGLRJUDSK\ 7KH OHIW FRURQDU\ ORFDOL]DWLRQ LV H[FHSWLRQDO :HUHSRUWDKLJKO\XQXVXDOIRUPRIOHIWVLQXVRI9DOVDOYDDQHXU\VPSUH VHQWLQJ ZLWK V\QFRSH DQG GHVFULEH WKH DSSHDUDQFHV REWDLQHG IURP D UDQJHRILPDJLQJWHFKQLTXHV
6
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
)LJXUHV 7UDQVWKRUDFLF HFKRFDUGLRJUDSK\ ORQJD[LV YLHZ VKRZLQJ DQ DQHXU\VP FROODSVLQJ LQ V\VWROH $ DQG H[SDQGLQJ LQ GLDVWROH % $R $RUWD /$/HIWDWULXP /9/HIWYHQWULFOH UHVRQDQFHLPDJLQJ 05, FRQILUPHGWKHSUHVHQFHRIDODUJHVDFFXODU DQHXU\VP RI WKH OHIW FRURQDU\ VLQXV )LJXUH 7KH SDWLHQW ZDV UHIHUUHGIRUFDUGLDFVXUJHU\DQGDGXDOFKDPEHUSDFHPDNHU
',6&866,21 6LQXVRI9DOVDOYDDQHXU\VPVDUHDQXQFRPPRQDQRPDO\RFFXUULQJLQ DSSUR[LPDWHO\ WR RI DOO FRQJHQLWDO FDUGLDF DEQRUPDOLWLHV 6LQXV RI 9DOVDOYD DQHXU\VPV DUH PRVW FRPPRQO\ FRQJHQLWDO 6HFRQGDU\FDXVHVRIVLQXVRI9DOVDOYDDQHXU\VPVDUHOHVVFRPPRQWKDQ FRQJHQLWDOOHVLRQVDQGPRUHIUHTXHQWO\DIIHFWWKHOHIWVLQXV6HFRQGDU\
'HSDUWPHQWRI&DUGLRORJ\DQG&DUGLRYDVFXODU6XUJHU\0HGLFLQHDQG3KDUPDFRORJ\)DFXOW\0RKDPPHG9,8QLYHUVLW\+RVSLWDO0DUUDNHFK 'HSDUWPHQWRI&DUGLRORJ\q0HGLFLQHDQG3KDUPDFRORJ\)DFXOW\+DVVDQ,,8QLYHUVLW\+RVSLWDO&DVDEODQFD0RURFFR &RUUHVSRQGHQFH 'U0XVWDSKD(O+DWWDRXLFKH]&KDUHL%G%UDKLP5RXGDQL0DDULI&DVDEODQFD0RURFFR7HOHSKRQH ID[HPDLOPHOKDW#\DKRRIU 5HFHLYHGIRUSXEOLFDWLRQ0DUFK$FFHSWHG6HSWHPEHU
e28
¬3XOVXV*URXS,QF$OOULJKWVUHVHUYHG
Can J Cardiol Vol 24 No 5 May 2008
Left sinus of valsalva aneurysm revealed by syncope
)LJXUH 7UDQVWKRUDFLF HFKRFDUGLRJUDSK\ VKRZLQJ PLOG YDOYXODU DRUWLF UHJXUJLWDWLRQ $ DQGGLDVWROLFIORZIURPWKHDQHXU\VPWKURXJKWKHOHIWYHQ WULFXODU /9 RXWIORZWUDFW % $R$RUWD
)LJXUH 7UDQVHVRSKDJHDOHFKRFDUGLRJUDPGHPRQVWUDWLQJWKHOHIWVLQXVRI 9DOVDOYDDQHXU\VP $Q $WKLQZDOOHGVDFFXODUVWUXFWXUHZLWKWKURPEXVLV VHHQLQFRPPXQLFDWLRQZLWKWKHOHIWFRURQDU\FXVSRIWKHDRUWLFYDOYH $ 7KHIUHHPHPEUDQHFRXOGEHVHHQFROODSVLQJLQGLDVWROH % DQGH[SDQGLQJ LQV\VWROH & $R$RUWD FDXVHV LQFOXGH EDFWHULDO HQGRFDUGLWLV WUDXPD V\SKLOLV WXEHUFXORVLV DQG%HKÐ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
Can J Cardiol Vol 24 No 5 May 2008
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
&21&/86,21 &RQVLGHULQJWKHFOLQLFDODQGLPDJLQJIHDWXUHVWKHDSSHDUDQFHRIWKH SUHVHQW OHVLRQ ZDV KLJKO\ XQXVXDO LH VL]H WKURPERVLV OHIW FRURQDU\ VLQXV ORFDWLRQ H[WHQVLRQ LQWR ERWK LQWHUYHQWULFXODU VHSWXP DQG OHIW YHQWULFXODURXWSXWDQGSUHVHQWDWLRQRIV\QFRSH :HDGGDQHZFDVHWR WKH OLWHUDWXUH GHWDLOLQJ WKH ILQGLQJV RI QRQLQYDVLYH LPDJLQJ RQ WKLV KLJKO\XQXVXDOIRUPRIVLQXVRI9DOVDOYDDQHXU\VPDUDUHFDXVHRIFRP SOHWHKHDUWEORFN
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
e29
$ODUJHDQHXU\VPRIDOHIWVLQXVRI9DOVDOYDLQYDGLQJ WKHLQWHUYHQWULFXODUVHSWXP²DUDUHFDXVHRIV\QFRSH 0XVWDSKD(O+DWWDRXL0'1DGLD&KDUHL0''ULVVL%RXP]HEUD0'6DLG&KUDLEL0'$KPHG%HQQLV0'
0(O+DWWDRXL1&KDUHL'%RXP]HEUD6&KUDLEL$%HQQLV$ ODUJH DQHXU\VP RI D OHIW VLQXV RI 9DOVDOYD LQYDGLQJ WKH LQWHUYHQWULFXODU VHSWXP q D UDUH FDXVH RI V\QFRSH &DQ - &DUGLRO HH
8QODUJHDQÑYULVPHGXVLQXVGH9DOVDOYD JDXFKHTXLHQYDKLWOHVHSWXPLQWHUYHQWULFXODLUH 8QHUDUHFDXVHGHV\QFRSH
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
/HVDQÑYULVPHVGXVLQXVGH9DOVDOYDVRQWUDUHVQRWDPPHQWFHX[GXVLQXV GH 9DOVDOYD JDXFKH (VW SUÑVHQWÑ OH FDV G XQH IHPPH GH DQV TXL D FRQVXOWÑ Í FDXVH G XQH V\QFRSH (OOH VRXIIUDLW G XQ EORFDJH FDUGLDTXH FRPSOHW / DXVFXOWDWLRQ D UÑYÑOÑ XQH UÑJXUJLWDWLRQ DRUWLTXH PRGÑUÑH / ÑFKRFDUGLRJUDSKLH WUDQVWKRUDFLTXH D UÑYÑOÑ TXH OD PHPEUDQH VRXV DRUWLTXH ÑWDLW OLÑH DX VHSWXP LQWHUYHQWULFXODLUH DYHF H[SDQVLRQ GH OD GLDVWROH HW FROODSVXV GH OD V\VWROH 2Q D FRQVWDWÑ XQ IOX[ GLDVWROLTXH HQ ERUGXUH GH FHWWH PHPEUDQH / ÑFKRFDUGLRJUDSKLH WUDQVVRSKDJLHQQH D UÑYÑOÑ XQH PDVVH N\VWLTXH TX RQ SHQVDLW ÒWUH XQ ODUJH DQÑYULVPH DYHF WKURPEXV SDULÑWDO GX VLQXV FRURQDLUH JDXFKH V ÑWHQGDQW GDQV OH VLQXV LQWHUYHQWULFXODLUH / LPDJHULH SDU UÑVRQDQFH PDJQÑWLTXH D FRQILUPÑ OH GLDJQRVWLF / H[SDQVLRQ GH O DQÑYULVPH DX VHSWXP LQWHUYHQWULFXODLUH D SURYRTXÑXQEORFDJHFDUGLDTXHFRPSOHWSUREDEOHPHQWSDUFRPSUHVVLRQGH ODIRQFWLRQQRUPDOHGXQXGDXULFXORYHQWULFXODLUH/HVUDSSRUWVGHFDVGH FHWWHDVVRFLDWLRQVRQWG XQHH[WUÒPHUDUHWÑ/HSUÑVHQWDUWLFOHHVWO XQGHV UDUHVUDSSRUWVGÑFULYDQWO DSSDULWLRQG XQDQÑYULVPHGXVLQXVGH9DOVDOYD JDXFKHÍO LPDJHULHSDUUÑVRQDQFHPDJQÑWLTXH
.H\:RUGV $QHXU\VP +HDUWEORFN ,PDJLQJ 6\QFRSH 9DOVDOYD
LQXVRI9DOVDOYDDQHXU\VPVUHPDLQXQFRPPRQDOWKRXJKWKHUDWH RI GLVFRYHU\ KDV LQFUHDVHG ZLWK WKH ZLGHVSUHDG DYDLODELOLW\ RI HFKRFDUGLRJUDSK\ 7KH OHIW FRURQDU\ ORFDOL]DWLRQ LV H[FHSWLRQDO :HUHSRUWDKLJKO\XQXVXDOIRUPRIOHIWVLQXVRI9DOVDOYDDQHXU\VPSUH VHQWLQJ ZLWK V\QFRSH DQG GHVFULEH WKH DSSHDUDQFHV REWDLQHG IURP D UDQJHRILPDJLQJWHFKQLTXHV
6
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
)LJXUHV 7UDQVWKRUDFLF HFKRFDUGLRJUDSK\ ORQJD[LV YLHZ VKRZLQJ DQ DQHXU\VP FROODSVLQJ LQ V\VWROH $ DQG H[SDQGLQJ LQ GLDVWROH % $R $RUWD /$/HIWDWULXP /9/HIWYHQWULFOH UHVRQDQFHLPDJLQJ 05, FRQILUPHGWKHSUHVHQFHRIDODUJHVDFFXODU DQHXU\VP RI WKH OHIW FRURQDU\ VLQXV )LJXUH 7KH SDWLHQW ZDV UHIHUUHGIRUFDUGLDFVXUJHU\DQGDGXDOFKDPEHUSDFHPDNHU
',6&866,21 6LQXVRI9DOVDOYDDQHXU\VPVDUHDQXQFRPPRQDQRPDO\RFFXUULQJLQ DSSUR[LPDWHO\ WR RI DOO FRQJHQLWDO FDUGLDF DEQRUPDOLWLHV 6LQXV RI 9DOVDOYD DQHXU\VPV DUH PRVW FRPPRQO\ FRQJHQLWDO 6HFRQGDU\FDXVHVRIVLQXVRI9DOVDOYDDQHXU\VPVDUHOHVVFRPPRQWKDQ FRQJHQLWDOOHVLRQVDQGPRUHIUHTXHQWO\DIIHFWWKHOHIWVLQXV6HFRQGDU\
'HSDUWPHQWRI&DUGLRORJ\DQG&DUGLRYDVFXODU6XUJHU\0HGLFLQHDQG3KDUPDFRORJ\)DFXOW\0RKDPPHG9,8QLYHUVLW\+RVSLWDO0DUUDNHFK 'HSDUWPHQWRI&DUGLRORJ\q0HGLFLQHDQG3KDUPDFRORJ\)DFXOW\+DVVDQ,,8QLYHUVLW\+RVSLWDO&DVDEODQFD0RURFFR &RUUHVSRQGHQFH 'U0XVWDSKD(O+DWWDRXLFKH]&KDUHL%G%UDKLP5RXGDQL0DDULI&DVDEODQFD0RURFFR7HOHSKRQH ID[HPDLOPHOKDW#\DKRRIU 5HFHLYHGIRUSXEOLFDWLRQ0DUFK$FFHSWHG6HSWHPEHU
e28
¬3XOVXV*URXS,QF$OOULJKWVUHVHUYHG
Can J Cardiol Vol 24 No 5 May 2008
Left sinus of valsalva aneurysm revealed by syncope
)LJXUH 7UDQVWKRUDFLF HFKRFDUGLRJUDSK\ VKRZLQJ PLOG YDOYXODU DRUWLF UHJXUJLWDWLRQ $ DQGGLDVWROLFIORZIURPWKHDQHXU\VPWKURXJKWKHOHIWYHQ WULFXODU /9 RXWIORZWUDFW % $R$RUWD
)LJXUH 7UDQVHVRSKDJHDOHFKRFDUGLRJUDPGHPRQVWUDWLQJWKHOHIWVLQXVRI 9DOVDOYDDQHXU\VP $Q $WKLQZDOOHGVDFFXODUVWUXFWXUHZLWKWKURPEXVLV VHHQLQFRPPXQLFDWLRQZLWKWKHOHIWFRURQDU\FXVSRIWKHDRUWLFYDOYH $ 7KHIUHHPHPEUDQHFRXOGEHVHHQFROODSVLQJLQGLDVWROH % DQGH[SDQGLQJ LQV\VWROH & $R$RUWD FDXVHV LQFOXGH EDFWHULDO HQGRFDUGLWLV WUDXPD V\SKLOLV WXEHUFXORVLV DQG%HKÐ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
Can J Cardiol Vol 24 No 5 May 2008
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
&21&/86,21 &RQVLGHULQJWKHFOLQLFDODQGLPDJLQJIHDWXUHVWKHDSSHDUDQFHRIWKH SUHVHQW OHVLRQ ZDV KLJKO\ XQXVXDO LH VL]H WKURPERVLV OHIW FRURQDU\ VLQXV ORFDWLRQ H[WHQVLRQ LQWR ERWK LQWHUYHQWULFXODU VHSWXP DQG OHIW YHQWULFXODURXWSXWDQGSUHVHQWDWLRQRIV\QFRSH :HDGGDQHZFDVHWR WKH OLWHUDWXUH GHWDLOLQJ WKH ILQGLQJV RI QRQLQYDVLYH LPDJLQJ RQ WKLV KLJKO\XQXVXDOIRUPRIVLQXVRI9DOVDOYDDQHXU\VPDUDUHFDXVHRIFRP SOHWHKHDUWEORFN
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
e29