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Dissection of the interventricular septum by unruptured right and left sinus of Valsalva aneurysms
Volume 122
Numbw
Brief Communications
6
1777
Fig. 2. A, Anteroposterior frame of the beginning of a pulmonary artery angiogram in one patient from group C (Fig. 1). It demonstrates the narrowed right pulmonary artery (arrowhead) from a migrated pulmonary artery band. The catheter course was from the aorta to the right ventricle to the right atrium to the left atrium (via an atria1 septal defect) to the left ventricle and finally to the pulmonary artery. B, Lateral frame from an azygous vein angiogram (patient from group D, Fig. 1). The course of the catheter was from the aorta to the ventricle
to the right atrium
to the superior
vena cava and finally
to the azygous vein,
where the tip of the catheter was viewed (arrow). modynamic and angiographic assessment in children with complex congenital heart disease. We thank Ms. Gloria Eigelberger for secretarial Anthony Stubblefield for artistic work.
help and
REFERENCES
Mullins CE, Neches WH, Reitman MJ, El-Said G, Riopel DA. Retrograde technique for catheterization of the pulmonary artery in transposition of the great arteries with ventricular septal defect. Am J Cardiol 1972;30:385-7. Laurin S, Lundstrom NR. Venous thrombosis after cardiac catheterization in infants. Acta Radio1 1987;28:241-6. Balfour IC, Jureidini SB, Nouri SM. Catheterizing modified Blalock-Taussig and ascending aorta to pulmonary artery shunts. Am J Cardiol 1991;68:279-80.
Dissection of the interventricular septum by unruptured right and left sinus of Valsalva aneurysms Hiisniye Ytiksel, MD,a Nuran Yazicioglu, MD,a Tayyar Sarioglu, MD,” Cengiz Celiker, MD,a Tufan Paker, MD,b Rasim Enar, MD,* Aydin Aytaq, MD,b and Cem’i Demiroglu, MD.” Istanbul,
Turkey
From the Departments of %linical Cardiology and bCardiovascular Institute of Cardiology, University of Istanbul. Reprint requests: Dr. Hiisniye Yiiksel, i.0. Kardiyoloji Enstitiisii, Istanbul, Turkey. 414133155
Surgery, Haseki,
Dissection of the interventricular septum is a rare complication of sinus of Valsalva aneurysm, and when it is not ruptured into a cavity, it is usually diagnosed at necropsy.lm3In this report we describe a patient in whom two aneurysms originating from the right and left coronary sinuses of Valsalva dissected into the interventricular septum resulting in aortic regurgitation and presenting with ventricular tachycardia attacks. A 32year-old man was admitted to our Institute because of precordial pain lasting for 2 hours, nausea, sweating, and palpitation. The day before admission during strenuous exercise he had experienced the same complaints twice. On admission the pulse rate was 96 beats/min, regular, and collapsing; and the blood pressure was 120/60 mm Hg. The apical pulse was palpable 1 cm lateral to the midclavicular line in the sixth intercostal space, and it was hyperdynamic. On the left sternal border, a grade 2/6 systolic ejection murmur radiating to the aortic area and a grade 3/6 early diastolic murmur radiating to the apex were heard. A teleroentgenogram showed left ventricular enlargement and the cardiothoracic ratio was 0.53. The electrocardiogram revealed sinus rhythm with right bundle-branch block. The hemogram, erythrocyte sedimentation rate, blood biochemistry, and urine analysis were normal. The serologic tests for syphilis were negative. Clinical findings did not suggest connective tissue disorders such as the Marfan or Ehlers-Danlos syndrome. M-mode echocardiography demonstrated dilatation of the left ventricular cavity, diastolic fluttering of the anterior leaflet of the mitral valve, and dilatation of the aortic root. Two-dimensional echocardiography in the parasternal long-axis view revealed an echofree space in the interventricular septum communicating with the aortic lumen through the right coronary sinus of
1778
December 1991 American Heart Journat
Brief Communications
Fig.
1. Two-dimensional echocardiogram in parasternal long-axis (A) and short-axis RV, right ventricle; LV, left ventricle; Prl. pulmonary artery: C’. cavity.
(6) views
(arrcJl(‘S)
Ao, Aorta;
Fig. 2. Aortic root angiogram in the left anterior oblique projection (A) and schematic drawing (B) demonstrating unruptured aneurysm of sinus of Valsalva (arrow). Lc‘. Left coronary sinus; An, aneurysm. Valsalva. The parasternal short-axis view showed two echo-free spaces between the aorta and the pulmonary artery (Fig. 1). At cardiac catheterization the left ventricular end-diastolic pressure was elevated, Left ventriculography demonstrated dilatation of the cavity, and aortography showed a tricuspid aortic valve, 3+ aortic regurgitation, and two unruptured aneurysms of sinuses of Valsalva dissecting the interventricular septum (Figs. 2 to 5). It was decided that the patient should be operated on with the tentative diagnosis of sinus of Valsalva aneurysm. A few
days before surgery, he suffered three attacks of ventricular tachycardia with a rate of 180 to 210 beats/min, and a pattern of left bundle branch block (Fig. 6). The attacks were refractory to medical treatment and he was treated with electrical conversion. The patient underwent open-heart surgery by standard cardiopulmonary bypass technique. During the exploration done through aortotomy and right ventriculotomy an aneurysmal sac of 5 x 6 cm in diameter and filled with fresh thrombi was identified in the infundibular septum. At the
Volume 122 Number 6
Brief Communications
1779
3. Aortogram in the 45degree right anterior oblique projection (A) and schematic drawing (6) demonstrating unruptured sinus of Valsalva aneurysm arising from the right coronary sinus (arrow). Ao, Aorta; LV, Left ventricle; An, aneurysm.
Fig.
B Fig. 4. Aortogram in 45-degree left anterior oblique projection demonstrating unruptured sinus of Valsalva aneurysms arising from the left and right coronary sinuses (arrows) (A) and schematic drawing (B). Ao, Aorta; LC, left coronary sinus; NC, noncoronary sinus; An, aneurysm; LV, Left ventricle.
right and left coronary cusps, two perforations with smooth edges, each 6 mm in diameter, were communicating with this aneurysmal sac (Fig. 7). These findings suggested the communication of the aneurysms of the right and left cor-
onary sinuses of Valsalva after dissection into the interventricular septum. After the thrombi in the aneurysmal sac had been removed, this cavity was approached with phcation by buttressed sutures passing through the right
December
1780
Brief Communications
American
1091
Heart Journal
Fig. 5. Aortic root injection demonstrating unrupt.ured sinus of Valsalva aneurysm arising from the right coronary sinus and dissecting the interventricular septum (arrows) (A) and schematic drawing (B). Ao, Aorta; IkAn, right coronarysinus aneurysm.
Fig. 6. Electrocardiogram ventricular tachycardia.
taken
during
an episode
of
ventricular side of the infundibular septum. Then the two perforations at the base of the right and left coronary cusps were closed with Dacron patch grafts. Since the coaptation of aortic cusps was found to be sufficent by direct vision, the aortic valve was not replaced. However, because aortic regurgitation continued, the aortic valve was replaced with a
Carbomedics (No. 23) protheses (Carbomedics Inc., Austin, Texas) in the second month after the first operation. After 2 years the patient is still followed-up in our outpatient clinic and does not have any complaints. Aneurysms may originate in one or more of the sinuses of Valsalva of the aort,ic valve. Depending on the anatomic location of the aneurysmal bulge, a number of complications may ensue. These aneurysms frequently rupture into a low-pressure area, usually into the right ventricle or right atrium, rarely into the pericardial sac, left atrium, left ventricle, mediastinum, or pulmonary artery. Dissection of the interventricular septum is a very rare complication of sinus of Valsalva aneurysm, and when it occurs it almost always originates from the right coronary sinus.l-” The case reported here is unusual in that two aneurysms originating from the right and left coronary sinuses dissected the ventricular septum forming a large cavity, communicating with each other without a secondary perforation into a cavity. The dissection of the interventricular septum by two aneurysms has not to our knowledge been described heretofore in the literature. Clinically, dissection of the interventricular septum can not be diagnosed until it ruptures into a cardiac cavity, leading to aortic regurgitation or to acute congestive heart failure, or unless other congenital cardiac anomalies are associated. The fact that our patient with unruptured sinus of Valsalva aneurysm dissecting the interventricular septum presented with chest pain and aortic regurgitation is of interest. Common electrocardiographic features of sinus of Valsalva aneurysms dissecting into the interventricular septum are atrioventricular and intraventricular conduction disturbances owing to encroachment of the aneurysm on the atrioventricular (AV) node or the bundle of His. In our patient the electrocardiogram also revealed right bundle branch block (RBBB). Ventricular tachycardia refractory
Volume122 Number
Brief Communications
6
178 1
7. Photograph obtained at surgery (A) and schematic drawings (B) of the two unruptured sinus of Valsalva aneurysms arising from the right and left coronary sinuses dissecting the infindubular septum and producing an aneursmal sac as seen during the operation. Ao, Aorta; PA, pulmonary artery; RC, right coronary sinus; LC, left coronary sinus; Znf S, infundibular septum; RV, right ventricle.
Fig.
to medical treatment occurred during hospitalization and did not recur after surgery; therefore it was thought to be related to the aneurysm. Arrhythmias are uncommon in sinus of Valsalva aneurysm and when they occur they are mostly supraventricular.4 Only a few cases of ventricular tachycardia caused by sinus of Valsalva aneurysm have been reported.ss6 Although the mechanism is unclear, ventricular tachycardia is suggested to result from the hemodynamic alterations occurring in this setting or from the mass effect of the aneurysm. Radiographic findings are not helpful in the diagnosis of sinus of Valsalva aneurysm. In our patient the teleroentgenogram was also unremarkable except for left ventricular enlargement as a result of aortic regurgitation. Recently, unruptured sinus of Valsalva aneurysms diagnosed by echocardiography performed for coexisting anomalies have been reported.3 In the case reported, echocardiography performed for the evaluation of aortic regurgitation revealed an echo-free space in the interventricular septum, and the diagnosis of unruptured sinus of Valsalva aneurysm was made by angiography. Surgical correction of an aneurysm dissecting the interventricular septum is not always simple. In this inst,ance, the usual procedure is closure of the aneurysmal cavity by suturing and placing a patch, and care should be taken after repair of the aneurysm to ensure competence of the aortic valve. REFERENCES
aneurysm of sinus of Valsalva: a rare complication diagnosed by echocardiography. Br Heart J 1983;50:293-5. 4. Taguchi K, Sasaki N, Matsuura U, Uemura R. Surgical correction of aneurysm of the sinus of Valsalva. A report of forty-five consecutive patients including eight with total replacement of the aortic valve. Am J Cardiol1969;23:180-91. 5. Heydorn WH, Nelson WP, Fitterer JD, Floyd GD, Strevey TE. Congenital aneurysm of the sinus of Valsalva protruding into the left ventricle. Review of diagnosis and treatment of the unruptured aneurysm. J Thorac Cardiovasc Surg 1976;71:83945. 6. Raizes GS, Smith HC, Vlietstra RE, Puga FJ. Ventricular tachycardia secondary to aneurysm of sinus of Valsalva. J Thorac Cardiovasc Surg 1979;78:110-15.
Echocardiographic demonstration growth of a left atrial myxoma
of rapid
William T. Pochis, MD, Michael W. Wingo, MD, Michael P. Cinquegrani, MD, and Kiran B. Sagar, MD. Milwaukee,
Wise.
Although intracardiac myxomas are rare, they represent the most common type of benign primary cardiac tumor. The growth rate of these neoplasms has been difficult to evaluate, and it has generally been estimated only by fol-
1. Gibbs NM, Harris EL. Aortic sinus aneurysms. Br Heart J 1961;23:131-9.
2. Onat A, Ersanii sinus aneurysms, interventricular 3. Chen WWC, Tai
0, Kanuni A, Aykan TB. Congenital aortic with particular reference to dissection of the septum. AM HEART J 1966;72:158-64. YT. Dissection of interventricular septum by
From the Division of Cardiology, Medical College of Wisconsin. Reprint requests: Kiran B. Sagar, MD, Division of Cardiology, Milwaukee County Medical Complex, 8700 W. Wisconsin Ave., Milwaukee, WI 53226. 414133148
Numbw
Brief Communications
6
1777
Fig. 2. A, Anteroposterior frame of the beginning of a pulmonary artery angiogram in one patient from group C (Fig. 1). It demonstrates the narrowed right pulmonary artery (arrowhead) from a migrated pulmonary artery band. The catheter course was from the aorta to the right ventricle to the right atrium to the left atrium (via an atria1 septal defect) to the left ventricle and finally to the pulmonary artery. B, Lateral frame from an azygous vein angiogram (patient from group D, Fig. 1). The course of the catheter was from the aorta to the ventricle
to the right atrium
to the superior
vena cava and finally
to the azygous vein,
where the tip of the catheter was viewed (arrow). modynamic and angiographic assessment in children with complex congenital heart disease. We thank Ms. Gloria Eigelberger for secretarial Anthony Stubblefield for artistic work.
help and
REFERENCES
Mullins CE, Neches WH, Reitman MJ, El-Said G, Riopel DA. Retrograde technique for catheterization of the pulmonary artery in transposition of the great arteries with ventricular septal defect. Am J Cardiol 1972;30:385-7. Laurin S, Lundstrom NR. Venous thrombosis after cardiac catheterization in infants. Acta Radio1 1987;28:241-6. Balfour IC, Jureidini SB, Nouri SM. Catheterizing modified Blalock-Taussig and ascending aorta to pulmonary artery shunts. Am J Cardiol 1991;68:279-80.
Dissection of the interventricular septum by unruptured right and left sinus of Valsalva aneurysms Hiisniye Ytiksel, MD,a Nuran Yazicioglu, MD,a Tayyar Sarioglu, MD,” Cengiz Celiker, MD,a Tufan Paker, MD,b Rasim Enar, MD,* Aydin Aytaq, MD,b and Cem’i Demiroglu, MD.” Istanbul,
Turkey
From the Departments of %linical Cardiology and bCardiovascular Institute of Cardiology, University of Istanbul. Reprint requests: Dr. Hiisniye Yiiksel, i.0. Kardiyoloji Enstitiisii, Istanbul, Turkey. 414133155
Surgery, Haseki,
Dissection of the interventricular septum is a rare complication of sinus of Valsalva aneurysm, and when it is not ruptured into a cavity, it is usually diagnosed at necropsy.lm3In this report we describe a patient in whom two aneurysms originating from the right and left coronary sinuses of Valsalva dissected into the interventricular septum resulting in aortic regurgitation and presenting with ventricular tachycardia attacks. A 32year-old man was admitted to our Institute because of precordial pain lasting for 2 hours, nausea, sweating, and palpitation. The day before admission during strenuous exercise he had experienced the same complaints twice. On admission the pulse rate was 96 beats/min, regular, and collapsing; and the blood pressure was 120/60 mm Hg. The apical pulse was palpable 1 cm lateral to the midclavicular line in the sixth intercostal space, and it was hyperdynamic. On the left sternal border, a grade 2/6 systolic ejection murmur radiating to the aortic area and a grade 3/6 early diastolic murmur radiating to the apex were heard. A teleroentgenogram showed left ventricular enlargement and the cardiothoracic ratio was 0.53. The electrocardiogram revealed sinus rhythm with right bundle-branch block. The hemogram, erythrocyte sedimentation rate, blood biochemistry, and urine analysis were normal. The serologic tests for syphilis were negative. Clinical findings did not suggest connective tissue disorders such as the Marfan or Ehlers-Danlos syndrome. M-mode echocardiography demonstrated dilatation of the left ventricular cavity, diastolic fluttering of the anterior leaflet of the mitral valve, and dilatation of the aortic root. Two-dimensional echocardiography in the parasternal long-axis view revealed an echofree space in the interventricular septum communicating with the aortic lumen through the right coronary sinus of
1778
December 1991 American Heart Journat
Brief Communications
Fig.
1. Two-dimensional echocardiogram in parasternal long-axis (A) and short-axis RV, right ventricle; LV, left ventricle; Prl. pulmonary artery: C’. cavity.
(6) views
(arrcJl(‘S)
Ao, Aorta;
Fig. 2. Aortic root angiogram in the left anterior oblique projection (A) and schematic drawing (B) demonstrating unruptured aneurysm of sinus of Valsalva (arrow). Lc‘. Left coronary sinus; An, aneurysm. Valsalva. The parasternal short-axis view showed two echo-free spaces between the aorta and the pulmonary artery (Fig. 1). At cardiac catheterization the left ventricular end-diastolic pressure was elevated, Left ventriculography demonstrated dilatation of the cavity, and aortography showed a tricuspid aortic valve, 3+ aortic regurgitation, and two unruptured aneurysms of sinuses of Valsalva dissecting the interventricular septum (Figs. 2 to 5). It was decided that the patient should be operated on with the tentative diagnosis of sinus of Valsalva aneurysm. A few
days before surgery, he suffered three attacks of ventricular tachycardia with a rate of 180 to 210 beats/min, and a pattern of left bundle branch block (Fig. 6). The attacks were refractory to medical treatment and he was treated with electrical conversion. The patient underwent open-heart surgery by standard cardiopulmonary bypass technique. During the exploration done through aortotomy and right ventriculotomy an aneurysmal sac of 5 x 6 cm in diameter and filled with fresh thrombi was identified in the infundibular septum. At the
Volume 122 Number 6
Brief Communications
1779
3. Aortogram in the 45degree right anterior oblique projection (A) and schematic drawing (6) demonstrating unruptured sinus of Valsalva aneurysm arising from the right coronary sinus (arrow). Ao, Aorta; LV, Left ventricle; An, aneurysm.
Fig.
B Fig. 4. Aortogram in 45-degree left anterior oblique projection demonstrating unruptured sinus of Valsalva aneurysms arising from the left and right coronary sinuses (arrows) (A) and schematic drawing (B). Ao, Aorta; LC, left coronary sinus; NC, noncoronary sinus; An, aneurysm; LV, Left ventricle.
right and left coronary cusps, two perforations with smooth edges, each 6 mm in diameter, were communicating with this aneurysmal sac (Fig. 7). These findings suggested the communication of the aneurysms of the right and left cor-
onary sinuses of Valsalva after dissection into the interventricular septum. After the thrombi in the aneurysmal sac had been removed, this cavity was approached with phcation by buttressed sutures passing through the right
December
1780
Brief Communications
American
1091
Heart Journal
Fig. 5. Aortic root injection demonstrating unrupt.ured sinus of Valsalva aneurysm arising from the right coronary sinus and dissecting the interventricular septum (arrows) (A) and schematic drawing (B). Ao, Aorta; IkAn, right coronarysinus aneurysm.
Fig. 6. Electrocardiogram ventricular tachycardia.
taken
during
an episode
of
ventricular side of the infundibular septum. Then the two perforations at the base of the right and left coronary cusps were closed with Dacron patch grafts. Since the coaptation of aortic cusps was found to be sufficent by direct vision, the aortic valve was not replaced. However, because aortic regurgitation continued, the aortic valve was replaced with a
Carbomedics (No. 23) protheses (Carbomedics Inc., Austin, Texas) in the second month after the first operation. After 2 years the patient is still followed-up in our outpatient clinic and does not have any complaints. Aneurysms may originate in one or more of the sinuses of Valsalva of the aort,ic valve. Depending on the anatomic location of the aneurysmal bulge, a number of complications may ensue. These aneurysms frequently rupture into a low-pressure area, usually into the right ventricle or right atrium, rarely into the pericardial sac, left atrium, left ventricle, mediastinum, or pulmonary artery. Dissection of the interventricular septum is a very rare complication of sinus of Valsalva aneurysm, and when it occurs it almost always originates from the right coronary sinus.l-” The case reported here is unusual in that two aneurysms originating from the right and left coronary sinuses dissected the ventricular septum forming a large cavity, communicating with each other without a secondary perforation into a cavity. The dissection of the interventricular septum by two aneurysms has not to our knowledge been described heretofore in the literature. Clinically, dissection of the interventricular septum can not be diagnosed until it ruptures into a cardiac cavity, leading to aortic regurgitation or to acute congestive heart failure, or unless other congenital cardiac anomalies are associated. The fact that our patient with unruptured sinus of Valsalva aneurysm dissecting the interventricular septum presented with chest pain and aortic regurgitation is of interest. Common electrocardiographic features of sinus of Valsalva aneurysms dissecting into the interventricular septum are atrioventricular and intraventricular conduction disturbances owing to encroachment of the aneurysm on the atrioventricular (AV) node or the bundle of His. In our patient the electrocardiogram also revealed right bundle branch block (RBBB). Ventricular tachycardia refractory
Volume122 Number
Brief Communications
6
178 1
7. Photograph obtained at surgery (A) and schematic drawings (B) of the two unruptured sinus of Valsalva aneurysms arising from the right and left coronary sinuses dissecting the infindubular septum and producing an aneursmal sac as seen during the operation. Ao, Aorta; PA, pulmonary artery; RC, right coronary sinus; LC, left coronary sinus; Znf S, infundibular septum; RV, right ventricle.
Fig.
to medical treatment occurred during hospitalization and did not recur after surgery; therefore it was thought to be related to the aneurysm. Arrhythmias are uncommon in sinus of Valsalva aneurysm and when they occur they are mostly supraventricular.4 Only a few cases of ventricular tachycardia caused by sinus of Valsalva aneurysm have been reported.ss6 Although the mechanism is unclear, ventricular tachycardia is suggested to result from the hemodynamic alterations occurring in this setting or from the mass effect of the aneurysm. Radiographic findings are not helpful in the diagnosis of sinus of Valsalva aneurysm. In our patient the teleroentgenogram was also unremarkable except for left ventricular enlargement as a result of aortic regurgitation. Recently, unruptured sinus of Valsalva aneurysms diagnosed by echocardiography performed for coexisting anomalies have been reported.3 In the case reported, echocardiography performed for the evaluation of aortic regurgitation revealed an echo-free space in the interventricular septum, and the diagnosis of unruptured sinus of Valsalva aneurysm was made by angiography. Surgical correction of an aneurysm dissecting the interventricular septum is not always simple. In this inst,ance, the usual procedure is closure of the aneurysmal cavity by suturing and placing a patch, and care should be taken after repair of the aneurysm to ensure competence of the aortic valve. REFERENCES
aneurysm of sinus of Valsalva: a rare complication diagnosed by echocardiography. Br Heart J 1983;50:293-5. 4. Taguchi K, Sasaki N, Matsuura U, Uemura R. Surgical correction of aneurysm of the sinus of Valsalva. A report of forty-five consecutive patients including eight with total replacement of the aortic valve. Am J Cardiol1969;23:180-91. 5. Heydorn WH, Nelson WP, Fitterer JD, Floyd GD, Strevey TE. Congenital aneurysm of the sinus of Valsalva protruding into the left ventricle. Review of diagnosis and treatment of the unruptured aneurysm. J Thorac Cardiovasc Surg 1976;71:83945. 6. Raizes GS, Smith HC, Vlietstra RE, Puga FJ. Ventricular tachycardia secondary to aneurysm of sinus of Valsalva. J Thorac Cardiovasc Surg 1979;78:110-15.
Echocardiographic demonstration growth of a left atrial myxoma
of rapid
William T. Pochis, MD, Michael W. Wingo, MD, Michael P. Cinquegrani, MD, and Kiran B. Sagar, MD. Milwaukee,
Wise.
Although intracardiac myxomas are rare, they represent the most common type of benign primary cardiac tumor. The growth rate of these neoplasms has been difficult to evaluate, and it has generally been estimated only by fol-
1. Gibbs NM, Harris EL. Aortic sinus aneurysms. Br Heart J 1961;23:131-9.
2. Onat A, Ersanii sinus aneurysms, interventricular 3. Chen WWC, Tai
0, Kanuni A, Aykan TB. Congenital aortic with particular reference to dissection of the septum. AM HEART J 1966;72:158-64. YT. Dissection of interventricular septum by
From the Division of Cardiology, Medical College of Wisconsin. Reprint requests: Kiran B. Sagar, MD, Division of Cardiology, Milwaukee County Medical Complex, 8700 W. Wisconsin Ave., Milwaukee, WI 53226. 414133148