Sinus of Valsalva aneurysms are rare congenital lesions that can arise from the right coronary (77%), noncoronary (23%) and, sometimes, the left coronary sinus of Valsalva (1
). Other less common etiologies include infective endocarditis and syphilis. More frequently encountered in men (2
), these aneurysms are usually detected in the third or fourth decade of life.
Often, unruptured sinus of Valsalva aneurysms are asymptomatic. These can become symptomatic once enlargement causes right ventricular outflow tract obstruction, coronary artery compression or conduction abnormalities (3
Rupture of sinus of Valsalva aneurysms may be spontaneous, triggered by chest trauma or exertion, or iatrogenic (cardiac catheterization). Rupture can occur into the right ventricle, right atrium or left atrium in decreasing order of frequency. Although uncommon, other sites into which rupture can occur are the left ventricle, interventricular septum, pericardium, pulmonary artery and superior vena cava. A transthoracic echocardiogram is diagnostic in the majority of cases. However, in one-quarter of patients, a transesophageal echocardiogram is required to delineate the anatomy.
Once these aneurysms rupture, the median survival is reduced to one to two years (if left untreated) and patients usually succumb to cardiac failure or infective endocarditis (4
). Early correction of the defect, either by direct closure or patch repair, is generally associated with a good outcome. Successful percutaneous closure of suitable lesions has also been reported.
In the present case, the patient probably had a congenital sinus of Valsalva aneurysm that enlarged gradually over time and ruptured into the right atrium causing right-sided heart failure. His uncontrolled hypertension and strenuous physical activity at work may have further promoted the rupture of the aneurysm.