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Ann Thorac Surg 2007;84:2119. doi:10.1016/j.athoracsur.2006.11.003
© 2007 The Society of Thoracic Surgeons
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Images in Cardiothoracic Surgery

Sinus of Valsalva Aneurysm Masquerading as Coronary Artery Disease

Edward W.K. Peng, MRCSa, Max Codispoti, FRCSa, Prem Venugopal, FRCSa, Colin Moore, FRCSb, Sai U. Prasad, FRCSa, William S. Walker, FRCSa,*

a Department of Cardiothoracic Surgery, Royal Infirmary of Edinburgh, Edinburgh, United Kingdom
b Department of Anaesthesia, Royal Infirmary of Edinburgh, Edinburgh, United Kingdom

* Address correspondence to Dr Walker, Department of Cardiothoracic Surgery, Royal Infirmary of Edinburgh, Little France Crescent, Edinburgh, EH16 4SA United Kingdom (Email: william.walker{at}luht.scot.nhs.uk).

A 53-year-old man had recurrent angina after single coronary artery bypass grafting (left internal thoracic artery [LITA] to the left anterior descending coronary artery [LAD]). Subsequent investigations showed an aortic root mass (A) (see computed tomographic scan, Figs 1A and 1B) behind the main pulmonary artery (MPA), arising from the aortic sinus (see Fig 2; transesophageal echocardiographic, long-axis view at mid-esophageal, aortic valve level; LA = left atrium; Asc Ao = ascending aorta; LV/RV = left/right ventricle; LVOT = left ventricle outflow tract). The LITA graft was patent, but the distal run-off was small, serving a hypokinetic region.


Figure 1
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  		Fig 1.
 

Figure 2
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  		Fig 2.
 
Intraoperatively a large true Sinus of Valsalva aneurysm was identified just below the left coronary orifice (Fig 3; LCA = left coronary artery). An uneventful pericardial patch closure of the aneurysm neck was performed. As the native LAD was small and the anterior left ventricular motion was poor, the vessel was not re-grafted.


Figure 3
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  		Fig 3.
 
An aortogram was not performed in his pre-CABG angiography, but an unusually large gap between the LAD and circumflex arteries (Cx) was already evident (Fig 4; OM = obtuse marginal; D1 = first diagonal branch). In retrospect, the smooth but long segment stenosis on the proximal LAD and the abnormal distance from circumflex suggested the presence of a space-occupying lesion. Sinus of Valsalva aneurysm is rare and only 1% arise from the left [1]. Coronary insufficiency as a result of external compression is uncommon but should be considered in angina with unusual angiographic appearances [2].


Figure 4
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  		Fig 4.
 


   References
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 References
 

  1. Guo DW, Cheng TO, Lin ML, Gu ZQ. Aneurysm of the sinus of Valsalva: a roentgenologic study of 105 Chinese patients Am Heart J 1987;114:1169-1177.[Medline]
  2. Lijoi A, Parodi E, Passerone GC, Scarano F, Caruso D, Iannetti MV. Unruptured aneurysm of the left sinus of Valsalva causing coronary insufficiency: case report and review of the literature Tex Heart Inst J 2002;29:40-44.[Medline]



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