PMC10073471_01
(A) The patient was cyanotic. (B) Electrocardiogram showing sinus rhythm and obvious ST-segment elevation in the aVR (red arrow) as well as depressions in the II, III, aVF, and V3-V6 leads (red arrow) when she laid flat and experienced angina pectoris. (C) The angina pectoris and ST segment abnormalities were relieved when she sat up.
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F1
A physical examination revealed lip cyanosis (Figure 1A) and a diastolic murmur at the left third intercostal space was present. Electrocardiography showed sinus rhythm, obvious ST-segment elevation in the aVR, and depression in the II, III, aVF, and V3-V6 leads when she lay flat and had angina pectoris attacks (Figure 1B). However, when she sat up for a few minutes, her symptoms and ST segment abnormalities disappeared (Figure 1C).
Echocardiogram showing (A) the unruptured left SVA (#) and non-coronary SVA (*), (B) enlarged left ventricle, (C) dilated aortic root, (D) ventricular septal membranous aneurysm (red arrow), (E) severe aortic regurgitation, and (F) right ventricular high pressure.
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F2
Echocardiography revealed large unruptured aneurysms in both the left (47 mm x 43 mm) and non-coronary (44 mm x 35 mm) sinuses (Figure 2A), along with an enlarged left ventricle (58 mm, Figure 2B), a dilated aortic root (52 mm, Figure 2C), a ventricular septal membranous aneurysm (19 mm x 16 mm, Figure 2D), severe aortic regurgitation (Figure 2E), right ventricular high pressure (pressure gradient 54 mmHg, Figure 2F), and decreased left ventricular systolic function (ejection fraction 51%).
CCTA images showing (A) the unruptured left SVA (#) and non-coronary SVA (*), the effect of the dilated left SVA on the (B) LM (red arrow) and the (C) LCX (red arrow), and (D) the dilated left SVA upwardly squeezed the pulmonary trunk (red arrow). (E) Sagittal plane view of the dual unruptured left/non-coronary SVAs. (F) Three-dimensional reconstruction image showing the dual unruptured left/non-coronary SVAs, passage of the LM and LCX, and compression of the LCX (red arrow).
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F3
Cardiac computed tomography angiography (CCTA) clearly showed a large unruptured left SVA (Figure 3A), which was anatomically close to the LM (Figure 3B) and proximal LCX (Figure 3C), causing severe narrowing of the vessel lumens. The dilated left SVA upwardly squeezed the pulmonary trunk (Figure 3D) and accelerated the maximum pulmonary blood flow to 3.7 m/s. The dilated non-coronary SVA adjoined the right atrium without a crevasse (Figure 3A). The sagittal plane view showed dual unruptured left/non-coronary SVAs (Figure 3E). Three-dimensional reconstruction images showed the LM and LCX running along the epicardium of the left SVA, with severe narrowing of the LCX (Figure 3F).
Intraoperative images confirmed the dual unruptured left (black arrow)/non-coronary (blue arrow) SVAs. The right coronary sinus (green arrow) was normal.
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F4
Operative findings confirmed a dual unruptured Valsalva aneurysm of the left coronary and non-coronary sinuses (Figure 4).