was remarkable for left ventricular hypertrophy. Transthoracic echocardiography showed a left ventricle with eccentric hypertrophy and impaired relaxation with a raised mass index of 105.6 g/m2, increased left atrial volume with a volume index of 42.51 cc/m2, and an intra-atrial membrane with a single large orifice. A pressure gradient across the defect of 3 mmHg was calculated. Pulmonary hypertension was notably absent. The patient started cardiomyopathy therapy and diuretics as needed for swelling and was followed over multiple visits in the cardiology clinic. She achieved appropriate medication titration with resolution of her congestive heart failure symptoms. On repeat echocardiogram performed one year after initiation of treatment, left ventricular mass index normalized to 74.3 g/m2, and
left atrial volume index normalized to 13.29 cc/m2. All medications were continued on a maintenance basis.
Discussion: Cor Triatriatum discovered in adulthood usually consists of one large single opening in the atrial membrane. This defect generally carries minimal hemodynamic consequence, with symptoms typically occurring secondary to fibrosis and calcification of the orifice. More restrictive anatomy such as smaller fenestrations generally present with severe symptoms in infancy or childhood. In this patient treatment for hypertensive cardiomyopathy relieved her symptoms, and her intra-atrial membrane appears to have had minimal effect on her clinical course. Surgery is considered the mainstay of treatment and may be considered if signs of pulmonary congestion develop.
SINUS OF VALSALVA ANEURYSM (SOVA) AS POSSIBLE ETIOLOGY OF ACUTE HEART FAILURE AND EXERTIONAL DYSPNEA Roxanne Nemati MD, Eric Arthur Pace MD, Vishal Vyas MD, Lee Arcement MD; Department of Medicine, Leonard J. Chabert Medical Center, Houma LA.
Introduction: Sinus of Valsalva Aneurysms (SOVAs) are often silent incidental findings but can cause complications such as right ventricular outflow tract (RVOT) obstruction, compression of coronary arteries, aortic insufficiency, and conduction issues. SOVAs are also at risk of rupture, which can cause a hemodynamically significant continuous shunt and, in rare cases, acute heart failure.
of the aneurysm with elevation in estimated pulmonary artery systolic pressure to 50 mmHg. His most recent echocardiogram showed a 35% ejection fraction with left ventricular end diastolic dimension of 6.9 cm, severe mitral regurgitation, mild tricuspid regurgitation, and 3.93 cm right SOVA involving the aortic root. He is currently undergoing evaluation with cardiothoracic surgery for surgical repair of SOVA with consideration for aortic root replacement versus patch repair of right Sinus of Valsalva with coronary artery bypass to the right coronary arter, mitral valve repair, possible tricuspid valve repair, and possible ascending aorta replacement. Discussion: SOVAs can occur congenitally or as acquired defects. The most common location is the right coronary cusp, as seen in this patient. Dilation of the aortic root is associated with development of aortic insufficiency and aortic dissection. Rupture into the right atrium and ventricle or interventricular septum may occur. Exertional dyspnea and heart failure are the most common presenting symptoms. In this patient, we observe a symptomatic SOVA in the setting of systolic heart failure. If his SOVA ruptures, a left-to-right shunt will occur between the aorta and right atria or ventricle. Surgical repair is recommended in this patient population to prevent further complication.
Case: A 62-year-old man with hypertension and chronic obstructive pulmonary disease
presented with a complaint of exertional dyspnea. Echocardiogram revealed an ejection fraction of 35% and severe mitral regurgitation with severe dilation of the sinuses of valsava and aortic root compatible with an aneurysm. Single photon emission computed tomography(SPECT) was negative for ischemia. Transesophageal echocardiogram was later performed during workup for atrial flutter, which revealed left and right ventricular hypertrophy with moderately reduced systolic function, left and right atrial enlargement, and a partially thrombosed 2 cm right SOVA. Computed tomography angiogram was performed, which showed a 3.4 cm right SOVA originating from right coronary cusp with mural thrombus (extending into the right ventricle) and dilated aortic root and ascending aorta. The patient was followed with annual echocardiograms over two years, which demonstrated progressive enlargement
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