A Cavernous Sinus of Valsalva Aneurysm-Juniper Publishers
JUNIPER PUBLISHERS-OPEN ACCESS JOURNAL OF CARDIOLOGY & CARDIOVASCULAR THERAPY
A 47 year old female healthy, asymptomatic farmer
underwent routine medical screening in rural China. A early diastolic
murmur was detected. Subsequent color doppler echocardiogram showed a
competent aortic valve but a fistulous communication of a perforated
Valsalva aneurysm into the left ventricle. Computed tomography revealed a
multi cavernous cauliflower-shaped Valsalva aneurysm involving the
whole aortic basisor bulbous aortae and all sinuses.
Introduction
A sinus of Valsalva aneurysm (SVA) was first
described by Thurman in 1840 [1]. A rare abnormality of the heart, a
sinus of Valsalva aneurysm, may be caused by a separation or localized
connective tissue dystrophy of the aortic tunica media and the annulus
fibrosus of the aortic valve [2]. Such a SVA may be congenital or
acquired [3] with an incidence as low as <1.5% among congenital heart
disease repairs [4]. It is the least common of all aortic aneurysms. If
not congenital but acquired causes include atherosclerosis, cystic
media necrosis, infective or post-traumatic injuries [5]. Sinus of
Valsalva aneurysmmore prevalent originates from the right coronary sinus
(70-90%), have been seen less commonly from the non-coronary sinus
(10-20%), and rarely from the left sinus (<5%) [6]. The incidences of
SVA are reported to be higher in Asian than Western populations, and
the male: female ratio was found to be 4:1 [7]. Un-ruptured sinus of
Valsalva aneurysms normally do not cause any symptoms unless they
rupture, causing fistulous communications, heart failure and death
[3,4,8,9].
A 47 year old female patient was admitted because
of an early diastolic murmur which was detected during a routine
medical screening of the rural population in north-east China in Jilin
Province, close to the North Korean border. The female patient, working
as a farmer and doing heavy work in the fields, was completely
asymptomatic and had no shortness of breath and
no dyspnea during her work. On admission she was in New York
Heart Association class I, regular sinus rhythm and
normal blood pressure, no diabetes, normal body mass index, no
prevalence of metabolic syndrome, but a heavy smoker. The early
diastolic murmur was confirmed but color doppler echocardiogram showed a
somewhat ‘difficult’ result. Investigated by different cardiologists we
received different interpretations. The first reported signs of a
congenital heart disease and a moderate ‘aortic’ incompetence but a
competent aortic bicuspid valve, however some signs of aortic valve (AV)
perforation.
The AV opening area was calculated 1.9cm2, the AV max
peak gradient (PG) 56mmHg, Ejection Fracture (Simpson) 74%, the
ascending aorta with a post-stenotic dilatation with a diameter of
ø4.2cm, LVIDd 4.2cm and AV V max 376 cm/sec. The other reported a
combined aortic valve lesion with stenosis and incompeence, some AV
vegetations, Vmax 471cm/sec and AV max PG 89mmHg. Repeated color doppler
echocardiograms showed a moderate flow through a perforated SVA into
the outflow tract of the left ventricle and thickened and deformed
obviously bi-leaflet aortic valve leaflets (Figure 1). Computed
tomography confirmed cavernous sinus of Valsalva aneurysmatic structures
right below the level of the sinutubular junction and fistulous
communications of a perforated SVA (Figure 2).Three-dimensional computed
tomography confirmed a dilated ascending aorta and multiple cavernous,
cauliflower-like Sinus of Valsalva structures surrounding the deformed
base of the aorta (Figure 3).
There was a clear indication for surgery due to a significant
aortic stenosis and a perforated SVA. However, the patient, a
farmer from the countryside in rural China, refused surgery
because the family could not afford the surgical treatment. There
are significant socio-economic disparities in China and a massive
gap between urban and rural population groups [10]. While the
wealthier share of the Chinese population has benefited from
advanced health technologies and spending on health care, the
poor have lost access to even the most essential services. In terms of rural-urban disparity across provinces, life expectancy
drops parallel to a rising share of rural population [11].
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