PMC5088544_01
Results of a 12-lead electrocardiogram on admission (A) and the time course change in the electrocardiogram (B). An electrocardiogram at admission showed sinus rhythm, first-degree atrioventricular (AV) block and left ventricular hypertrophy. On hospital day 5, complete AV block was observed. An accelerated junctional rhythm (AJR) dissociated with atrial rhythm was subsequently seen on hospital day 12. The heart rhythm changed from AJR to sinus rhythm with first-degree AV block on hospital day 19. The PQ interval gradually shortened with time.
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AV block with a PQ interval of 0.22 seconds, and left ventricular hypertrophy (Fig. 1A). All four sets of blood culture grew Streptococcus sanguinis. AV block (Fig. 1B), which was the most likely cause of CHF. A transvenous pacing lead was immediately placed at the right ventricular apex for backup pacing at a rate of 60 beats per minute. The AJR persisted until hospital day 19, at which point electrocardiography showed sinus rhythm and first degree AV block with a PQ interval of 0.28 seconds (Fig. 1B).
Transthoracic echocardiography on hospital day 28 (A), transesophageal echocardiography on hospital day 29 (B), left ventriculography at the outflow tract on hospital day 41 (C), and multidetector computed tomography on hospital day 29 (D). The echo-free space dilated during systole (white arrow) and collapsed during diastole, resulting in pulsatile motion (A, B). The contrast medium was seen entering from the left ventricular outflow tract (LVOT) into the space between the left atrium and sinus of Valsalva during systole (surrounded by the black broken line) (C). The pseudoaneurysm was indicated by red arrows. Multidetector computed tomography was useful to clarify the locational relationship between the pseudoaneurysm and coronary artery (D). LCA: left coronary artery, RAO: right anterior oblique
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TTE and TEE (Fig. 2A and B). The echo-free space dilated during systole and collapsed during diastole, resulting in a pulsatile motion. The communication site around the aneurysm-like structure was unclear on MDCT, and the three-dimensional MDCT image was not useful to clarify the locational relationship between the aneurysm-like structure and coronary artery (Fig. 2D). The contrast medium was seen entering from the LV outflow tract (LVOT) into the space between the left atrium (LA) and the sinus of Valsalva during systole and returning to the LVOT during diastole without any communication with other adjacent structures (Fig. 2C).
Intraoperative image. The root of the ascending aorta was opened and both non-coronary and left coronary cusps were resected, revealing the fistula in the non-coronary sinus of Valsalva (green arrow). Ao: ascending aorta, LV: left ventricle
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During the surgery, a fistula was detected connecting the LVOT just below the non-coronary aortic cusp and the pseudoaneurysm (Fig. 3), and this fistula was closed with a patch.