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ST Elevation Not Due to Coronary Occlusion: An Unusual Case
October 2010, Vol 138, No. 4_MeetingAbstracts Case Reports: Wednesday, November 3, 2010 | October 2010
ST Elevation Not Due to Coronary Occlusion: An Unusual Case Shuchita Gupta, MD; Shweta Gupta, MD; Vincent Figueredo, MD Albert Einstein Medical Center, Philadelphia, PA Chest. 2010;138(4_MeetingAbstracts):100A. doi:10.1378/chest.10695
Abstract INTRODUCTION: Acute cardiac catheterization with percutaneous coronary intervention is recommended for all patients with suspected ST elevation myocardial infarction (STEMI). However, a small proportion of patients with suspected STEMI suffer from other conditions. We present a patient with apparent STEMI who was found to have an unusual condition on cardiac catheterization. CASE PRESENTATION: A 47 year old male with a past medical history of coronary artery disease status post angioplasty presented with severe sub-sternal chest pain radiating to his left arm, similar to his previous anginal pain. Physical examination revealed jugulovenous distension with a holosystolic murmur at the left sternal border. His electrocardiogram revealed a right bundle branch block (RBBB) with ST elevation in leads V1, V2 and ST depression in leads II, III, aVF, V3-V6, and his Troponin I was elevated. Treatment for acute coronary syndrome was initiated. He underwent emergent cardiac catheterization in view of ongoing chest pain, which revealed normal coronary arteries and a ruptured sinus of Valsalva (RSOV) aneurysm with a left to right shunt, with contrast moving from the right coronary artery cusp in to the right atrium. Transthoracic echocardiogram confirmed RSOV off the aortic valve with the classic windsock appearance in the right atrium by the tricuspid valve. He then underwent emergent sternotomy and repair of RSOV aneurysm with pericardial patches to right atrium and aortic sinus with good operative results. Unfortunately, he had a complicated post-operative course with multi-organ failure and eventually expired after a month. DISCUSSIONS: Congenital sinus of Valsalva aneurysm was first described by Hope in 1839. Rupture of sinus of Valsalva (RSOV) is a rare entity, with an incidence of 0.1% in the western population. It is more prevalent in Asians because of the higher incidence of supracristal (subpulmonic) ventricular septal defects with which it may be associated. Right coronary sinus is the most common site of aneurysm formation. Rupture may occur in to any cardiac chamber, most common being the right ventricle. Presentation of RSOV may vary from an asymptomatic murmur to acute onset of chest pain, acute heart failure, acute cardiogenic shock and death. When rupture occurs in to the right atrium, RBBB with or without right ventricular hypertrophy may be noted on the electrocardiogram. Echocardiography is an excellent tool to define and diagnose the lesion and quantify its severity. Prompt diagnosis and surgical therapy are essential. Our patient presented with EKG
changes suspicious for a STEMI, hence the diagnosis was made early with cardiac catheterization. This case thus illustrates a rare condition with an uncommon presentation. CONCLUSION: RSOV is a rare condition that may present as an acute coronary syndrome. Diagnosis requires a high degree of clinical suspicion. Mortality is high without prompt diagnosis and surgical treatment. DISCLOSURE: Shuchita Gupta, No Financial Disclosure Information; No Product/Research Disclosure Information 10:30 AM - 12:00 PM
References 1 HassinkRJ , van Herwerden, LA, Meijburg, HW.2010Mar) A rare and difficult diagnosis: a ruptured sinus of valsalva aneurysm.J Am Coll Cardiol55,9921. [CrossRef] [PubMed] 2 LindsayAC , Mahesh, B, Gaer, JA, Dalby, MC.2009May) Ruptured sinus of Valsalva aneurysm presenting as ST-elevation myocardial infarction.Nat Rev Cardiol6,5379– 82. [CrossRef] [PubMed]
ST Elevation Not Due to Coronary Occlusion: An Unusual Case Shuchita Gupta, MD; Shweta Gupta, MD; Vincent Figueredo, MD Albert Einstein Medical Center, Philadelphia, PA Chest. 2010;138(4_MeetingAbstracts):100A. doi:10.1378/chest.10695
Abstract INTRODUCTION: Acute cardiac catheterization with percutaneous coronary intervention is recommended for all patients with suspected ST elevation myocardial infarction (STEMI). However, a small proportion of patients with suspected STEMI suffer from other conditions. We present a patient with apparent STEMI who was found to have an unusual condition on cardiac catheterization. CASE PRESENTATION: A 47 year old male with a past medical history of coronary artery disease status post angioplasty presented with severe sub-sternal chest pain radiating to his left arm, similar to his previous anginal pain. Physical examination revealed jugulovenous distension with a holosystolic murmur at the left sternal border. His electrocardiogram revealed a right bundle branch block (RBBB) with ST elevation in leads V1, V2 and ST depression in leads II, III, aVF, V3-V6, and his Troponin I was elevated. Treatment for acute coronary syndrome was initiated. He underwent emergent cardiac catheterization in view of ongoing chest pain, which revealed normal coronary arteries and a ruptured sinus of Valsalva (RSOV) aneurysm with a left to right shunt, with contrast moving from the right coronary artery cusp in to the right atrium. Transthoracic echocardiogram confirmed RSOV off the aortic valve with the classic windsock appearance in the right atrium by the tricuspid valve. He then underwent emergent sternotomy and repair of RSOV aneurysm with pericardial patches to right atrium and aortic sinus with good operative results. Unfortunately, he had a complicated post-operative course with multi-organ failure and eventually expired after a month. DISCUSSIONS: Congenital sinus of Valsalva aneurysm was first described by Hope in 1839. Rupture of sinus of Valsalva (RSOV) is a rare entity, with an incidence of 0.1% in the western population. It is more prevalent in Asians because of the higher incidence of supracristal (subpulmonic) ventricular septal defects with which it may be associated. Right coronary sinus is the most common site of aneurysm formation. Rupture may occur in to any cardiac chamber, most common being the right ventricle. Presentation of RSOV may vary from an asymptomatic murmur to acute onset of chest pain, acute heart failure, acute cardiogenic shock and death. When rupture occurs in to the right atrium, RBBB with or without right ventricular hypertrophy may be noted on the electrocardiogram. Echocardiography is an excellent tool to define and diagnose the lesion and quantify its severity. Prompt diagnosis and surgical therapy are essential. Our patient presented with EKG
changes suspicious for a STEMI, hence the diagnosis was made early with cardiac catheterization. This case thus illustrates a rare condition with an uncommon presentation. CONCLUSION: RSOV is a rare condition that may present as an acute coronary syndrome. Diagnosis requires a high degree of clinical suspicion. Mortality is high without prompt diagnosis and surgical treatment. DISCLOSURE: Shuchita Gupta, No Financial Disclosure Information; No Product/Research Disclosure Information 10:30 AM - 12:00 PM
References 1 HassinkRJ , van Herwerden, LA, Meijburg, HW.2010Mar) A rare and difficult diagnosis: a ruptured sinus of valsalva aneurysm.J Am Coll Cardiol55,9921. [CrossRef] [PubMed] 2 LindsayAC , Mahesh, B, Gaer, JA, Dalby, MC.2009May) Ruptured sinus of Valsalva aneurysm presenting as ST-elevation myocardial infarction.Nat Rev Cardiol6,5379– 82. [CrossRef] [PubMed]