PMC8634469_01
Transthoracic echocardiogram (TTE) showed a giant aneurysm at the parasternal aortic short axis view that was originated from the left sinus of Valsalva (A). Communication of the blood flow was detected between the aneurysm and the aorta (B). TTE, transthoracic echocardiogram; RVOT, right ventricle outflow tract; Ao, aorta; LA, left atrium; red star, sinus of Valsalva aneurysm (SoVA).
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The transesophageal echocardiography (TEE) showed a giant aneurysm at the parasternal aortic short axis view, which originated from the left sinus of Valsalva (Figure 1A). Communication of blood flow was detected between the aneurysm and the aorta (Figure 1B).
Coronary computed tomography angiogram (CCTA) images of the SoVA obtained before (A-D) and after (E-H) surgical treatment. (A,E) show a continuous curved vessel reconstruction of the left main and left anterior descending coronary arteries based on enhanced spiral CT before (A) and after the surgery (E). (B,E) show the CT coronal section of the reconstructed heart before (B) and after (F) the surgical exclusion. (C) shows a three-dimensional reconstruction model of the aneurysm before surgery, and (G) shows the same view absent the aneurysm after the surgical exclusion. (D,H) show the long-axis curvilinear reformation of the left main coronary artery (LMCA) before (D) and after the surgery (H). LMCA is identified with a red rectangle demonstrating extrinsic compression before surgery that has resolved after. The PT and LA were eliminated in (C,F) to show the LMCA. LMCA, left main coronary artery (yellow arrow); LAD, left anterior descending coronary artery (black arrow); PT, pulmonary trunk; LV, left ventricle; Ao, aorta; RV, right ventricle; LVOT, left ventricle outflow tract; LV, left ventricle; red star, SoVA; red line, the neck of the aneurysm; red arrow, right coronary artery; white arrow, left circumflex coronary artery.
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The left main coronary artery (LMCA) opening originated from the neck of the aneurysm, and its proximal portion extended above the body of the aneurysm (Figures 2A-D). Postoperative CCTA showed that the SoVA was not enhanced during the computed tomography angiogram and the blood flow through the LMCA recovered significantly, with the percentage diameter stenosis that decreased from 62% to 21% (Figures 2E-H).
The CAG showed the severely dilated left sinus of Valsalva and the contrast agent was preserved and rotated in a circle (A). The aneurysm compressed the LMCA (yellow arrow) in the upward direction with significant LMCA seriously narrowing (B). No critical stenosis was observed in LAD. Red stars, the outline of the SoVA; CAG, coronary artery angiography; LMCA, left main coronary artery; LAD, left anterior descending coronary artery, black arrow; white arrow, left circumflex coronary artery.
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Coronary angiography (CAG) confirmed these findings by showing persistent swirling of contrast within the dilated aneurysm (Figure 3; Supplementary Video 1).
The gross view of the aneurysm in situ initially observed before (A) and after (B) the surgical exclusion. The neck of the aneurysm originated from the left sinus of Valsalva (shown in the yellow-dotted border), and the LMCA originated from the LCC, just above the neck of the aneurysm (A). A patch (shown in black-dotted border) was used to close the opening of the aneurysm, thereby, reconstructing the left coronary sinus (B). LMCA, left main coronary artery; Ao, aorta; SV, superior vena cava; LCC, left coronary cusp; RCC, right coronary cusp; blue triangle, the opening of the LCMA; white triangle, the opening of the right coronary artery; white arrow, left and right coronary valve.
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Accordingly, the patient underwent surgical exclusion of the aneurysm and placement of a heart patch (Figure 4).