A rare case of echocardiography in diagnosing sinus valsalva aneurysm with shunting into the right ventricle. Aneurysm of the sinus of valsalva

The sinus of Valsalva is part of the aortic valve, formed from the walls of the right, left and posterior semilunar valve and presented in the form of a kind of sinus. This formation plays the role of a connecting link between the left ventricle of the heart and the largest artery in the body. The main function of the aortic valve, and with it the sinus of Valsalva itself, is to prevent the return of blood that has passed into the aorta as a result of ventricular contraction. Violation of the functioning of this department of the largest blood vessel in the body can lead to overflow of blood into the ventricles of the heart, which, without the provision of qualified medical care, will lead to death.

Aneurysm of the sinus of Valsalva- an anomaly in the structure of the aorta, manifested as a pathological protrusion of the walls of the aortic valve. This pathology is quite rare and is most often congenital.

Causes

Despite all the achievements of medicine, the exact cause of the onset of this pathology has not been established to date. Scientists suggest that the formation of an aneurysm of the sinus of Valsalva during fetal development may occur if the aortic wall is weakly connected to the annulus fibrosus. So, most likely this protrusion is formed due to detachment of the middle layer of the aortic valve.

It is believed that the progression of inflammatory lesions of the circulatory system or heart disease, mechanical damage to the aorta due to chest trauma, infection with tertiary syphilis, and tuberculosis can provoke the triggering of the mechanism for the formation of an aneurysm of the sinuses of Valsalva. The risk group also includes people with a burdened family history of cardiovascular disease and suffering from various degenerative diseases.

Rupture of the sinus of Valsalva can be the result of trauma, physical overstrain, an attack of arterial hypertension, or the progression of a bacterial lesion of the inner lining of the heart.

Symptoms

The aneurysm of the sinuses of Valsalva proceeds mainly in a latent form, causing neither pathological changes in the nature of the blood flow, nor any disruption in the functioning of the heart until the protrusion reaches an impressive size. If the pathological focus has sufficiently increased in volume, signs of arrhythmia may occur.

When an aneurysm of the sinuses of Valsalva ruptures, the patient usually complains of shortness of breath, retrosternal pain, hand tremor, a feeling of severe weakness, and cold sweating. In addition, facial cyanosis, decreased blood pressure, palpitations, and systolic tremors may be observed. In most cases, rupture of an aneurysmal lesion of the aortic sinuses is accompanied by cardiac asthma and alveolar edema of the lungs, manifested by attacks of sudden suffocation, severe coughing, severe weakness, sensation of dull blows in the chest area, discharge of a large amount of sputum with blood impurities, swelling of the cervical veins, palpation of the filiform and irregular pulse.

Diagnostics

If you suspect the development of an aneurysm of the sinuses of Valsalva, phonocardiography is prescribed, which allows you to assess the nature of the systolic murmur, the high amplitude of which will indicate the presence of such a defect. An ECG is not used in diagnosing this pathology, since changes will be traced on the electrocardiogram only in the event of a rupture of the aneurysm.

As part of the diagnosis, an X-ray examination of the chest is also performed. So, on an x-ray, a suspicion of the development of an aneurysm of the sinuses of Valsalva can cause an increase in the heart in size.

Echocardiography is one of the most effective methods for detecting aneurysmal lesions of the sinuses of Valsalva. Thanks to such a study, it is possible to detect an aneurysmal protrusion before it ruptures.

Confirmation of the diagnosis in case of manifestation of symptoms corresponding to an aneurysm of the sinuses of Valsalva can also be done using MSCT aortography or contrast CT of the heart.

Treatment

In the case of an aneurysm of the sinuses of Valsalva, conservative therapy is prescribed only to slow the progression of the pathological process. Basically, the therapeutic course of this direction is limited to taking antihypertensive drugs.

As a rule, patients with a diagnosis of aneurysm of the sinuses of Valsalva are referred for surgery, during which an aneurysmal sac is resected, followed by correction of the aortic walls with a special patch. In the event of a rupture of the aneurysm of the sinuses of Valsalva, as a rule, the resulting hole is sutured and, with the help of prosthetics, the junction of the aortic valve ring with the walls of the aorta is strengthened. For the duration of such surgical interventions, the patient is connected to a heart-lung machine.

The prognosis for the success of treatment directly depends on how timely the diagnosis was. Thus, an aneurysm that has reached a sufficiently large size can provoke the rapid development of acute coronary insufficiency, which often leads to the death of the patient even before any measures are taken.

It often happens that patients with a clinical picture of heart failure come to ECHOCG. In such patients, unfortunately, the picture on echocardiography is completely unpredictable, ranging from the absence of changes to rare pathologies that must be operated on. That is why each echocardiogram requires extremely careful study, especially if the patient has complaints of shortness of breath, swelling or pain in the heart.

Patient A., without any medical records, aged 50! years complains of shortness of breath on exertion. Looking ahead, I’ll say that after the diagnosis was made by echocardiography and a more meticulous questioning, relatives reported that something was found in A. by ultrasound of the heart, but they didn’t remember what.

So here is the research protocol.

Parasternal long-axis section shows dilatation of the right coronary sinus, suggesting a diagnosis of an aneurysm. I put the arrow on the protrusion, which catches the eye - something unlike the normal echo picture of the aortic root section.

As you know, the main rule of ultrasound is that the pathology should be visible in two sections, so I studied the section of the aortic root along the short axis (Fig. 2) and saw that there is a protrusion here too.

If there are any pathologies on the echocardiogram, our next step is to turn on the CFM and look for a reset. So, this is what happened with the CDC. Showing the apical projection. In the form of red fountains with an aliasing effect, the discharge of blood into the right ventricle is visible.

The cause of this patient's dyspnoea is pulmonary hypertension due to an aneurysm of the sinus of Valsalva with right-sided discharge. The case is subject to consultation with a cardiac surgeon to decide whether to close the vent or open cardiac surgery. If the cardiac surgeon does not deem it necessary to perform an operation, the cardiologist will prescribe A. the necessary pathognomonic therapy, which will lead to an improvement in her well-being and the disappearance of symptoms.

Therefore, echocardiography is so important in diagnosing the cause of heart failure.

The sinuses (sinuses) of the aorta at the site of attachment of the semilunar valves of the aortic valve are named after the Italian anatomist Valsalva. With an aneurysmal expansion of the wall in this area, a heart defect occurs, more often due to congenital weakness of the connective tissue.

The manifestation of signs of the disease occurs when the aneurysm ruptures - pain in the chest, a drop in cardiac activity. Treatment requires vascular plasty using a heart-lung machine.

Read in this article

Reasons for development

Congenital aortic aneurysm in the area of the sinuses of Valsalva is the most common variant of this pathology, it is found more often in boys. All three sinuses can be affected, but in the vast majority it is the right coronary. The size of the formation is from 1 to 3 cm.

Isolated bulging of the vessel in the root zone is rare, patients usually suffer from, or, narrowing of the pulmonary artery.

The formation of this aortic defect is caused by the impact of adverse factors on a pregnant woman:

viral infections,
syphilis,
diabetes,
intoxication,
medicines,
taking alcohol or drugs,
smoking,
harmful working conditions,
toxicosis,
threatened miscarriage.

The formation of a congenital defect is based on the weakening of elastin fibers at the site of attachment of the aorta to the valve ring. This happens even during fetal development. After birth, there is no aneurysm, and as the vessel grows, the wall of the vessel becomes thin and ruptures under the action of blood pressure.

Such an event can occur in childhood, but most often patients live into their 20s or 30s, unaware of their illness.

Acquired pathology is formed after tuberculosis, syphilitic or rheumatic infection, against the background of traumatic injury. With a strong blow to the chest, the aneurysm can rupture with the passage of blood into the cavity of the pericardial sac. It almost instantly causes death.

Symptoms of an aneurysm of the sinus of Valsalva

Many patients do not have heart problems until the moment of rupture. Sometimes an aneurysm interferes with the free flow of blood through the pulmonary artery or compresses the conductive fibers in the myocardium, provoking various types.

Rupture of the aneurysmal sac occurs in the cavity of the heart. This leads to the discharge of blood into the corresponding chamber. If the formation is located in the right or left coronary sinus, then the half of the heart of the same name overflows. The non-coronary sinus is close to the right atrium, so the aneurysm breaks into it.

The course of the defect can be with a gradual increase in clinical signs. This is possible only with the simultaneous development of another congenital anomaly in the structure of the heart, which compensates for the discharge of blood. In this case, patients complain of due to compression of the coronary arteries, fainting associated with transverse heart block. If there is only an aneurysm of the sinus of Valsalva, then the condition worsens very quickly.

An increase in blood pressure, intense physical activity, a blow to the chest, trauma, an inflammatory process in the myocardium, or endocarditis can lead to a rupture.

Patients at the same time feel unbearable pain in the chest and abdomen (due to overflow of the liver), difficulty breathing, rapid heartbeat, dizziness.

The ejection of blood from the ventricles decreases, which is accompanied by an increase in circulatory failure, pulmonary edema. With a sudden overflow of the right ventricle, there may be cardiac arrest, since its myocardium is much weaker than that of the left one. The pressure decreases, when listening to the heart, the noise of a “working machine” is determined, trembling during the period of contraction.

In the period before the rupture, some patients hear a murmur in systole or diastole along the edge of the sternum on the left side.

Watch the video about congenital heart defects:

Condition Diagnostics

To confirm the diagnosis, an instrumental examination is performed.

ECG, echocardiography

It is impossible to draw a conclusion about the presence or absence of an aneurysm in a patient. If there is an overflow of the right or left half, then there are indirect signs of overload.

As with other anomalies of the structure of the heart, ultrasound data are used to diagnose aortic disease. Either transthoracic or s can be performed. In this case, the following symptoms are revealed:

an enlarged sinus that protrudes into one of the chambers of the heart;
discharge of blood during diastole (during a breakthrough);
reverse flow of blood at the aortic valve.

X-ray and other methods

Plain chest x-ray shows an enlarged shadow of the heart, especially in the right section, an enhanced pulmonary pattern due to a crowded right ventricle.

To determine the exact dimensions before surgical correction, patients are prescribed aortography, (visualization of the ventricles), MRI as an independent method or in conjunction with angiography.

Treatment of an aneurysm of the sinus of Valsalva

The abnormal structure of the sinus of Valsalva can only be eliminated with surgical treatment. In this case, the following actions are envisaged:

Connection to a heart-lung machine.
The protrusion is stitched and cut off.
The defect site is covered with a synthetic patch from the side of the aorta or heart chamber.

An alternative technique is to retract the sac into the aortic lumen, then suture it and partially remove it. The difficulty of the operation arises in the immediate vicinity of the aneurysm and the coronary artery. In this case, preference is given to suturing the cavity from the side of the heart. At the same time, other malformations or aortic valve plastic surgery can be corrected.

Prognosis for patients

The severity of this disease is due to the fact that the aneurysm does not manifest itself until the moment of rupture. And when this event occurs, an operation is indicated as soon as possible, which is difficult to implement, since neither the doctor nor the patient has suspicions about the impending danger.

If a large defect occurs between the aorta and the heart, then this causes a large shunt of blood and death due to acute heart failure.

Even with a relatively small breakthrough, patients cannot live more than 2 years with such a defect, since blood stasis in the arterial and venous system inevitably develops, ending in cardiac arrest.

If the operation is carried out in a timely manner, then the chances of survival increase significantly. Such patients show a gradual return to normal activities, but they should be observed by a cardiologist for a long period of time (at least a year).

A sinus of Valsalva aneurysm occurs due to weakness in the aortic wall at the valve insertion site. The disease is often congenital. Symptoms until the moment of rupture are absent or do not differ in specificity. The breakthrough of the aneurysm occurs in the nearby heart with the development of acute or chronic circulatory failure.

For diagnosis, the most informative are ultrasound of the heart and MRI. Treatment is only surgical, without it, patients are doomed.

Features of the disease

Sinus of Valsalva aneurysm most often occurs in the region of the right coronary sinus, in a quarter of cases - in the region of the posterior (non-coronary) sinus, and in only five percent of patients it is registered in the region of the left coronary sinus. Occasionally, an aneurysm of all three sinuses occurs at the same time, but such a case is so rare that it does not occur in the practice of most cardiac surgeons. The aneurysmal sac can reach a size of three centimeters.

Any of the defects may develop with or without rupture of an aneurysm in the presenting heart. In half of the cases, congenital aneurysm of the sinuses of Valsalva is combined with other heart defects. Basically, this is and, aortic insufficiency, and.

Very often, the aneurysm ends in one or more perforations that allow the aortic root to communicate with the corresponding cardiac chamber. Doctors identify several patterns of aneurysm rupture in certain parts of the heart.

Left and central aneurysms of the right coronary sinus usually rupture into the outflow tract of the right ventricle.
The aneurysm of the right side of the right sinus breaks either into the cavity of the right atrium, or into the inflow department of the right ventricle.
Very rare aneurysms of the left coronary sinus usually rupture extracardiac, into the cavity of the right atrium or right ventricle.

Read more about the causes of a root aneurysm at the level of the sinuses of Valsalva.

Causes

The main cause of aneurysm of the sinuses of Valsalva is considered to be poor heredity. In people whose close relatives suffer from various defects of the heart muscle, the likelihood of having a child with a defect is many times higher. Difficult pregnancy and poor development of the fetus in the womb can also cause an aortic aneurysm of the sinus of Valsalva.

The formation of this defect is based on the weakness of the connection between the annulus fibrosus and the aortic wall, which leads to a weakening of the media (the middle layer of the aorta) and the formation of an aneurysm. At the time of the birth of the child, the defect may not be detected. In the future, throughout life, the aneurysmal sac increases in size, the walls become thinner and, as a result, tear. The rupture of an aneurysm in a patient occurs at the age of twenty-five to forty years, but it also happens in childhood.

Acquired ASV can occur after suffering complex inflammatory and degenerative diseases, as well as severe chest injuries. All these reasons lead to dystrophy of the connective tissue, which is located on the inner surface of the sinuses.

Symptoms

In young children, an aneurysm of the sinuses of Valsalva is almost always asymptomatic. Characteristic signs can appear only in the presence of breakthroughs that occur during physical exertion:

broken heartbeat;
nausea;
pale appearance;
loss of consciousness;
severe chest pain;
dyspnea;
dizziness.

Ailments come with a sharp and gradual deterioration of well-being. This factor depends on the size of the gap and the volume of blood discharged into the chambers of the heart.

Diagnostics

Physically, you can determine some of the signs of an aneurysm of the sinuses of Valsalva:

continuous and loud systolic murmur in the upper chest;
pulmonary rales;
pasternal trembling;
murmur from the back at the base of the heart.

Diagnostics goes like this:

Electrocardiography does not show any specific changes. In some cases, an overload of both ventricles and an atrioventricular blockade, as well as a junctional rhythm, are noticeable. Phonocardiography reveals high-amplitude noise.
Echocardiography determines the condition of the sinuses, the proximal aorta, the aortic valve and the entire structure surrounding them. With the help of transesophageal echocardiography, you can find the exact location of the rupture and determine the degree of bleeding.
The thoracic radiograph shows an increased volume of the heart, especially its right section, and an increase in the pulmonary pattern.
The method of retrograde aortography (injection of a contrast agent into the aortic root) can distinguish the location of the aneurysmal sac, its size and the presence of perforations.
Also, to identify this heart disease, a cardiologist may prescribe an MRI of the heart muscle and ventriculography.

You will learn about what an aneurysm of the sinuses of Valsalva looks like from the following video:

Treatment

Medical and therapeutic

Conservative treatment of an aneurysm of the sinuses of Valsalva is aimed at hemodynamic stabilization, elimination of arrhythmia, prevention and treatment of infective endocarditis and cardiac ischemia.

It is important to know which pills and other medicines are used for aortic aneurysm of the sinus of Valsalva. ACE inhibitors, diuretics, nitrates and β-blockers are used. Standard endocarditis prophylaxis is performed.

How to recover from an aortic aneurysm of the sinus of Valsalva with the help of surgery, read below.

Surgery for aortic aneurysm of the sinus of Valsalva

Elimination of ASV is possible only surgically - with the help of an operation. The aneurysm of the sinuses of Valsalva is repaired. Surgical intervention is performed with the connection of cardiopulmonary bypass. Cardiac surgeons perform the operation through the right sections of the heart muscle.

The aneurysm is resected and followed by plasty and suturing, which are reinforced with special pads. If necessary, aortic valve prosthetics and additional leaflet plasty are also performed.

When an aneurysm of the sinuses of Valsalva ruptures, its transcatheter closure is performed. It is carried out under the control of echocardiography using special devices. Plastic aneurysm of the sinus of Valsalva gives a 100% recovery.

Scheme of supracoronary prosthetics of the ascending aorta

Disease prevention

Disease prevention includes:

maintaining a healthy lifestyle;
walks in the open air;
lack of physical activity;
regular follow-up with a cardiologist;
expert advice.

Complications

Possible complications with this heart disease:

myocardial ischemia and angina pectoris;
infective endocarditis (very often, such a disease is associated with microscopic tears);
acute or progressive sinus of Valsalva with congestive heart failure or aortic valve insufficiency;
compression of the conduction system of the heart muscle, followed by its blockade;
aortopulmonary or aortobronchial fistula;
systemic embolism with impaired blood flow through a dilated unruptured sinus.

Forecast

Fatal cases mainly occur when an aneurysm of the sinuses of Valsalva ruptures, followed by acute severe aortic valve insufficiency. If you do not operate on the sinus rupture that has arisen, then death occurs in about a year, sometimes a little later. It all depends on its location and the magnitude of the blood flow disorder.

After surgery, the survival prognosis is very good, especially if there is no damage to the aortic valve. The lethal outcome is only five percent of the total mass of patients.

The prognosis for patients with an unruptured defect is unknown, since the disease is completely asymptomatic.

With transthoracic echocardiography, it is possible to visualize the aorta: the root, proximal sections of the ascending section and part of the descending section behind the left atrium - from the projection along the long parasternal axis of the left ventricle, and the arch and part of the descending aorta - from the suprasternal access. However, transesophageal echocardiography is more informative, the indication for which is the suspicion of aortic disease.

Diseases of the aorta of the heart

Normally, the aorta is defined as a hollow tubular formation emanating from the left ventricle with even walls up to 3 mm thick and with a diameter of: from 2.0 to 3.7 cm - in the ascending section, no more than 2.4 cm - in the region of the arc and from 1.0 to 1.3 cm - in the descending section. In this case, the systolic amplitude of movement of the aortic root should be more than 7 mm.

The most common pathology is atherosclerosis, which is manifested by a change in the walls of the aorta: local or diffuse thickening and compaction, unevenness of the contour (Fig. 8.10).

Rice. 8.10. Signs of atherosclerosis of the aorta. Image from the parasternal position along the long axis in B- and M-modes

Based on the severity of these changes, the degree of damage to the walls of the aorta is determined: mild, moderate, severe.

(Fig. 8.11) complicate atherosclerotic lesions, but may also be a manifestation of other diseases, such as nonspecific aortoarteritis, Marfan's syndrome, syphilitic aortitis, aortic median necrosis ( Erdheim's disease), as well as the result of trauma or concomitant pathology in congenital anomalies, such as bicuspid aortic valve .

There are the following morphological variants of the aneurysm:

fusiform- diffuse expansion of the aortic segment;
saccular - expansion of part of the circumference of the aorta in the form of a protrusion.

In addition, “true” aneurysms are distinguished, in which the pathological expansion of the lumen affects all the membranes of the vessel wall, and “false”, which are a rupture of the inner or middle layer of the aortic wall, resulting in an expansion of its segment, and the wall at the same time consists of outer shell and/or perivascular clot.

Direct echocardiographic evidence of aortic aneurysm is a significant, more than twice, expansion of the lumen of the aorta. A decrease in wall pulsation is characteristic. Thrombi located near the wall can be detected.

Dissection (dissection) of the aorta

Dissection (dissection) of the aorta can also be diagnosed by transthoracic echocardiography and TEE. The sensitivity of these methods for this pathology is 80% and 94%, the specificity is 95% and 98%, respectively, which is comparable to those of computed tomography - 83% and 100%.

According to the DeBakey classification, the following 3 types of aortic dissection are distinguished, depending on the location of the exfoliated intima:

type I - in the ascending aorta, arch and descending aorta;
type II - in the ascending aorta;
type III - in the descending aorta.

The main sign of aortic dissection during echocardiography is an additional contour of the vessel wall, which divides the vessel into two parts (Fig. 8.12).

When an aneurysm ruptures, a violation of the integrity of its wall is visualized with detachment of the intima, defined as a linear, mobile, floating formation in the lumen of the aorta - a defect in the aneurysm wall. With aortic valve insufficiency, there is the possibility of an aneurysm rupture moving to the aortic ring, sinuses of Valsalva, brachiocephalic vessels, prolapse of the exfoliated intima into the cavity of the left ventricle.

Sometimes you can see a hematoma located near the aortic contour of positive thrombotic masses. Aortic insufficiency, effusion in the pericardial cavity, and less commonly, effusion in the pleural cavity are also considered specific for aneurysm rupture.

When examining a dissecting aortic aneurysm, not only the presence of its signs is determined, but also the place of intimal detachment, its prevalence, and also indicate the severity of aortic regurgitation.

Aneurysm of the sinuses of Valsalva

Aneurysm of the sinuses of Valsalva, characterized by a protrusion of the wall of one of the sinuses (their names correspond to the leaflets of the aortic valve - left coronary, right coronary, non-coronary) into the adjacent cardiac chamber, is usually a congenital anomaly (for example, in Marfan's syndrome), due to the weakness of the connection of the aortic wall with the annulus fibrous valve , although it can be registered with aorto-arteritis or supravalvular aortic stenosis.

The main morphological form of an aneurysm of the sinuses of Valsalva- isolated in combination with other defects (septal defect, patent ductus arteriosus, coarctation of the aorta, bicuspid aortic valve, etc.).

echocardiographic sign This pathology is a saccular protrusion of the sinus wall into one of the cavities of the heart: the right one - into the right atrium or the output section of the right ventricle, the left one - into the left atrium, non-coronary - into the right atrium or the output section of the right ventricle.

When a sinus is ruptured, an echocardiogram made from a parasternal approach in the projection along the short axis at the level of the aorta visualizes both the break of the echo signal in the area of the aneurysmal sac (single or multiple), and signs of volume overload of that chamber, damage to the right coronary sinus, most rarely - left sinus.

Dopplerography and color flow register turbulent blood flow in the corresponding cavity.

It has been noted that children may detection of dilatation of the sinuses of Valsalva, more often non-coronary, in which the expansion of the sinus does not reach degree of aneurysm. Long-term observation of such patients indicates the possibility of a benign nature of this pathology and its spontaneous disappearance as the child grows.

Dilatation of the aorta

Dilatation of the aorta is a characteristic sign of connective tissue dysplasia and is detected in Marfan syndromes (Fig. 8.14),

Ehlers-Danlos, etc. In this case, mitral valve prolapse and additional trabeculae in the cavity of the left ventricle are simultaneously determined, less often - dilatation of the pulmonary artery trunk, etc.

In the absence of these syndromes, the possibility of other causes of aortic dilatation - post-stenotic dilatation, arterial hypertension, aortitis, median necrosis - should be assessed. About idiopathic dilatation of the aorta can only be said after a rigorous study, excluding all of the above.

Rice. 8.14. Aortic dilatation in Marfan syndrome