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Spontaneous echocardiographic contrast within an unruptured sinus of Valsalva aneurysm: A potential embolic source diagnosed by transesophageal echocardiography
Spontaneous Echocardiographic Contrast Within an Unruptured Sinus of Valsalva Aneurysm: A Potential Embolic Source Diagnosed by Transesophageal Echocardiography Eric Steinberg, MD, Herrick Wun, BS, Joseph Bosco, and Itzhak Kronzon, MD,
New York, New York
A 75-year-old male patient had an unexplained transient ischemic attack. Transesophageal echocardiography revealed a large, unruptured Sinus o f Valsalva
aneurysm which contained spontaneous echo contrast. This finding represents a potential source o f embolism. (J Am Soc Echocardiogr 1996;9:880-1).
IT
U n r u p t u r e d sinus o f Valsalva aneurysm is a rare anomaly that is frequently asymptomatic and n o t associated with any physical findings. We describe a 75-year-old patient with a transient ischemic attack w h o was f o u n d to have spontaneous echo contrast in an u n r u p t u r e d sinus o f Valsalva. T h e diagnosis was made by transesophageal echocardiography and was confirmed by angiography and surgery.
CASE REPORT A 75-year-old previously healthy man was admitted to the hospital after a 1-hour episode of aphasia that had resolved spontaneously. On admission, the blood pressure was 120/70 mm Hg. Examination of the heart revealed normal heart sounds without any murmur. There were no carotid bruits and a carotid duplex study was normal. A transthoracic echocardiogram was of poor quality but did not reveal any gross abnormalities. Electrocardiogram and 24-hour electrocardiographic monitoring (Holter) were unremarkable. To evaluate the possibility of cardiogenic embolism further, the patient underwent transesophageal echocardiography (Figure 1). This study revealed a large, noncoronary sinus of Valsalva aneurysm that bulged into and compressed the left atrium. Swirling spontaneous echo contrast ("smoke") was clearly visualized within the aneurysm, but no evidence ofthrombus was seen. There was no communication between the aneurysm and any cardiac chamber or major blood vessel, nor was there any evidence of aortic insufficiency. The study did not reveal any other From the Department of Medicine, New York University Medical Center and Manhattan Veterans Affairs Medical Center. Reprint requests: Itzhak Kronzon, MD, 560 First Ave., New York, NY I0016. Copyright © 1996 by the American Society of Echocardiography. 0894-7317/96 $5.00 + 0 27/4/71585 880
Figure 1 Transesophageal echocardiogram (transverse view). Large noncoronary sinus of Valsalva aneurysm (AN) filled with spontaneous echo contrast is bulging and compressing left atrial cavity. (A, Anterior; P, posterior; R, right; L, left; LA, left atrium; AO, aorta; AV, aortic valve; LV, left ventricle; MV, mitral valve; RVO, right ventricular outflow tract.) potential cardiovascular source of emboli. Based on the size of the aneurysm and the probability that it was the source of the patient's embolus, the patient was referred for angiography and later for surgery, which confirmed the transesophageal echocardiographic findings.
DISCUSSION I n m o s t cases, u n r u p t u r e d sinus o f Valsalva aneurysms are n o t associated with any symptoms. T h e
Journal of the AmericanSocietyof Echocardiography Volume 9 Number 6
m o s t frequent complication associated with sinus o f Valsalva aneurysm is rupture. This may be fatal w h e n it occurs in the pericardial space. M o r e commonly, rupture creates left-to-fight shunts or c o m m u n i c a tions between the aneurysm and a left-sided chamber. There also have been cases o f right ventricular outflow obstruction, 1 c o r o n a r y artery compression with infarction, 2 c o n d u c t i o n disturbances, 3 and endocarditis associated with this anomaly. Embolic events associated with u n r u p t u r e d sinus ofValsalva aneurysms are extremely rare. A review o f the literature revealed two cases o f u n r u p t u r e d sinus o f Valsalva aneurysm presenting with embolization. 4'5 I n those cases, however, a t h r o m b u s was n o t e d within the u n r u p t u r c d sinus o f Valsalva. O u r patient's findings were remarkable for spontaneous echo contrast ( " s m o k e " ) within the aneurysmal cavity. This finding is k n o w n to be associated with embolic events, and correlation between embolic events and left atrial and left ventricular smoke has n o w been well established. Spontaneous intracavitary echocontrast is detected better by transesophageal echocardiography. 6 A n e u r y s m o f the sinus o f Valsalva
Steinberg et al.
881
is another site where b l o o d stagnation can occur. Thus this potential source o f embolism can be detected better by transesophageal echocardiography. REFERENCES
1. Haraphongae M, Ayudha RK, Judgatt B, Russal R. Isolated, unrnptured sinus of Valsalva aneurysm producing tight ventricular outflow tract obstruction. Cathet Cardiovasc Diagn 1990;19:98-102. 2. Chipps HD. Aneurysm of sinus of Valsalva causing coronary occlusion. Arch Pathol Lab Med 1941;31:627-30. 3. Lee EB, Krieger OJ, Lee NK. Congenital aneurysm of the noncoronary sinus of Valsalva leading to complete heart block. Ann Intern Med 1956;45:525-34. 4. Shahrabani RM, Jairaj PS. Uuruptured aneurysm of the sinus ofValsalva: a potential source of cerebrovascular embolism. Br Heart J 1993;69:266-7. 5. Wortham DC, Gorman PD, Hull RW, Vernalis MN, Gaither NS. Uuruptured sinus of Valsalva aneurysm presenting with embolization. Am Heart J 1993;25:896-8. 6. Daniel WG, Nellessen U, Schroder E, et al. Left atrial spontaneous echo contrast in mitral valve disease: indication for an increased thromboembolic risk. J Am Coil Cardiol 1988;11: 1204-11.
New York, New York
A 75-year-old male patient had an unexplained transient ischemic attack. Transesophageal echocardiography revealed a large, unruptured Sinus o f Valsalva
aneurysm which contained spontaneous echo contrast. This finding represents a potential source o f embolism. (J Am Soc Echocardiogr 1996;9:880-1).
IT
U n r u p t u r e d sinus o f Valsalva aneurysm is a rare anomaly that is frequently asymptomatic and n o t associated with any physical findings. We describe a 75-year-old patient with a transient ischemic attack w h o was f o u n d to have spontaneous echo contrast in an u n r u p t u r e d sinus o f Valsalva. T h e diagnosis was made by transesophageal echocardiography and was confirmed by angiography and surgery.
CASE REPORT A 75-year-old previously healthy man was admitted to the hospital after a 1-hour episode of aphasia that had resolved spontaneously. On admission, the blood pressure was 120/70 mm Hg. Examination of the heart revealed normal heart sounds without any murmur. There were no carotid bruits and a carotid duplex study was normal. A transthoracic echocardiogram was of poor quality but did not reveal any gross abnormalities. Electrocardiogram and 24-hour electrocardiographic monitoring (Holter) were unremarkable. To evaluate the possibility of cardiogenic embolism further, the patient underwent transesophageal echocardiography (Figure 1). This study revealed a large, noncoronary sinus of Valsalva aneurysm that bulged into and compressed the left atrium. Swirling spontaneous echo contrast ("smoke") was clearly visualized within the aneurysm, but no evidence ofthrombus was seen. There was no communication between the aneurysm and any cardiac chamber or major blood vessel, nor was there any evidence of aortic insufficiency. The study did not reveal any other From the Department of Medicine, New York University Medical Center and Manhattan Veterans Affairs Medical Center. Reprint requests: Itzhak Kronzon, MD, 560 First Ave., New York, NY I0016. Copyright © 1996 by the American Society of Echocardiography. 0894-7317/96 $5.00 + 0 27/4/71585 880
Figure 1 Transesophageal echocardiogram (transverse view). Large noncoronary sinus of Valsalva aneurysm (AN) filled with spontaneous echo contrast is bulging and compressing left atrial cavity. (A, Anterior; P, posterior; R, right; L, left; LA, left atrium; AO, aorta; AV, aortic valve; LV, left ventricle; MV, mitral valve; RVO, right ventricular outflow tract.) potential cardiovascular source of emboli. Based on the size of the aneurysm and the probability that it was the source of the patient's embolus, the patient was referred for angiography and later for surgery, which confirmed the transesophageal echocardiographic findings.
DISCUSSION I n m o s t cases, u n r u p t u r e d sinus o f Valsalva aneurysms are n o t associated with any symptoms. T h e
Journal of the AmericanSocietyof Echocardiography Volume 9 Number 6
m o s t frequent complication associated with sinus o f Valsalva aneurysm is rupture. This may be fatal w h e n it occurs in the pericardial space. M o r e commonly, rupture creates left-to-fight shunts or c o m m u n i c a tions between the aneurysm and a left-sided chamber. There also have been cases o f right ventricular outflow obstruction, 1 c o r o n a r y artery compression with infarction, 2 c o n d u c t i o n disturbances, 3 and endocarditis associated with this anomaly. Embolic events associated with u n r u p t u r e d sinus ofValsalva aneurysms are extremely rare. A review o f the literature revealed two cases o f u n r u p t u r e d sinus o f Valsalva aneurysm presenting with embolization. 4'5 I n those cases, however, a t h r o m b u s was n o t e d within the u n r u p t u r c d sinus o f Valsalva. O u r patient's findings were remarkable for spontaneous echo contrast ( " s m o k e " ) within the aneurysmal cavity. This finding is k n o w n to be associated with embolic events, and correlation between embolic events and left atrial and left ventricular smoke has n o w been well established. Spontaneous intracavitary echocontrast is detected better by transesophageal echocardiography. 6 A n e u r y s m o f the sinus o f Valsalva
Steinberg et al.
881
is another site where b l o o d stagnation can occur. Thus this potential source o f embolism can be detected better by transesophageal echocardiography. REFERENCES
1. Haraphongae M, Ayudha RK, Judgatt B, Russal R. Isolated, unrnptured sinus of Valsalva aneurysm producing tight ventricular outflow tract obstruction. Cathet Cardiovasc Diagn 1990;19:98-102. 2. Chipps HD. Aneurysm of sinus of Valsalva causing coronary occlusion. Arch Pathol Lab Med 1941;31:627-30. 3. Lee EB, Krieger OJ, Lee NK. Congenital aneurysm of the noncoronary sinus of Valsalva leading to complete heart block. Ann Intern Med 1956;45:525-34. 4. Shahrabani RM, Jairaj PS. Uuruptured aneurysm of the sinus ofValsalva: a potential source of cerebrovascular embolism. Br Heart J 1993;69:266-7. 5. Wortham DC, Gorman PD, Hull RW, Vernalis MN, Gaither NS. Uuruptured sinus of Valsalva aneurysm presenting with embolization. Am Heart J 1993;25:896-8. 6. Daniel WG, Nellessen U, Schroder E, et al. Left atrial spontaneous echo contrast in mitral valve disease: indication for an increased thromboembolic risk. J Am Coil Cardiol 1988;11: 1204-11.