Valsalva Aneurysm Filled with Thrombi Mimicking a Cardiac Tumor
A 59-year-old man was referred to our hospital due to an abnormal electrocardiogram, atrial fibrillation and a complete atrioventricular blockage. He didn't feel any symptoms such as dyspnea on effort, chest pain or fatigue. He showed moderate cardiomegaly in a chest radiograph and non-significant findings in blood tests, including tumor markers. TTE showed an enlarged left ventricular dimension, deteriorating systolic function (ejection fraction=32%) and low echoic mass (26×30 mm) between the atrial septum and the non-coronary sinus (). A coronary angiography showed disease in three vessels, including chronic total occlusion of the proximal left anterior descending artery. No feeder artery to the cardiac mass was observed. Initially we planned to perform a biopsy of the mass using fluoroscopic and transesophageal echo-guidance, because we suspected the mass was a cardiac tumor. However, the patient refused the biopsy due to the high risk and invasiveness of the procedure. Thus, we performed noninvasive modalities, including cardiac MRI and TEE, in an attempt to make an accurate diagnosis of the mass.\nA cardiac MRI showed that the mass lesion presented high signal intensity mostly, mixed with a low focal signal intensity on a T2-weighted fast spin-echo image and a dark signal intensity on a T1-weighted fast spin-echo image (). These MRI findings suggested that the mass was a subacute hemorrhage. In addition, the sagittal oblique cine MRI revealed that the mass was connected to the non-coronary sinus and was not located in the right atrium (). A TEE showed a dilated non-coronary sinus filled with an irregular-surfaced low echoic mass (). By integration of the MRI findings of tissue characterization together with the accurate location of the mass with TEE findings of the irregular surface of the mass and a partial defect of the edge of the non-coronary sinus, we diagnosed that the cardiac mass was a thrombosed Valsalva aneurysm that had perforated the inter-atrial septum before. Surgery was performed.\nA non-coronary sinus plasty and a coronary-aorta bypass graft were performed. The operative findings revealed a defected and thrombi filled non-coronary sinus (), which coincided with the preoperative diagnosis from both the MRI and TEE. In addition, the patient underwent cardiac resynchronization therapy to address the complete atrioventricular block and reduced left ventricular function. The patient's postoperative clinical course was uneventful.