Ruptured Right Sinus of Valsalva Aneurysm to the Right Atrium Mimicking Acute Myocardial Infarction
A 39-year-old male patient presented with chest discomfort and dyspnea that had lasted for 12 hours. A grade 3/6 diastolic murmur was auscultated at the left third intercostal space, and an electrocardiogram showed mild ST segment depression on precordial leads (). The creatine kinase MB (CK-MB), troponin T, and serum creatinine levels were 208.4 ng/mL (reference value, < 5 ng/mL), 2.54 ng/mL (reference value, < 0.1 ng/mL), and 4.1 mg/dL, respectively. Transthoracic echocardiography (TTE) showed slightly reduced left ventricular systolic function (ejection fraction, 51%) with apical akinesia and mild aortic regurgitation (grade 1). The pattern of apical akinesia was dissimilar to that associated with the apical ballooning caused by stress-induced cardiomyopathy. The patient had unstable vital signs, and his echo window was very poor due to severe obesity; a thorough echocardiographic study was impossible. Emergency coronary angiography was planned under the impression of AMI, but cardiac arrest occurred immediately before coronary angiography. Therefore, cardiopulmonary resuscitation (CPR) was performed. Coronary angiography revealed no significant luminal narrowing. Coronary flow was within normal limits, and there was no evidence of plaque disruption or thrombosis. However, an aortogram showed a shunt from the aorta to the right heart. Cardiac catheterization showed elevated right ventricular and pulmonary artery pressure (peak, 55 mmHg). The Qp/Qs was estimated to be approximately 3.15. Subsequent transesophageal echocardiography (TEE) revealed shunted flow from the SVA of right coronary cusp to the right atrium and grade 1 aortic regurgitation ().\nEmergency repair of the ruptured SVA was performed. Exposure of the ascending aorta and right atrium revealed a SVA on the right coronary cusp, which had ruptured to the right atrium (). The aortic valve was morphologically normal in appearance with no detectable valve dysfunction. After successful direct closure of the rupture site, intraoperative TEE result did not showed shunted flow or aortic valve dysfunction.\nCardiac function and mental status were not restored after surgery. Preoperative multiple organ failure (MOF) was aggravated despite intraaortic balloon pump with a high dose of cardiotonics and continuous renal replacement therapy. Electroencephalography showed that severe cerebral injury might have been caused by the prolonged preoperative CPR. The patient died on the ninth day after the operation.