Sinus of Valsalva Pseudoaneurysm and Mechanical Aortic Valve Endocarditis

ABSTRACT: We present the case of a 54-year-old male with a St. Jude aortic valve replacement who presented with fever and a new diastolic murmur. An echocardiogram identified a pseudoaneurysm that appeared to originate from the left sinus of Valsalva. In anticipation of open valve surgery, a 64-slice computed tomographic (CT) angiogram was performed to characterize the size and location of the pseudoaneurysm. In addition, the CT scan was able to rule out significant coronary artery disease and obviate the need to perform a potentially high-risk catheter-directed angiogram in the setting of an infected pseudoaneurysm. J INVASIVE CARDIOL 2010;22:195
Case Description A 54-year-old male with a St. Jude aortic valve replacement (AVR) (St. Jude Medical, Inc., St. Paul, Minnesota) implanted 5 years previously presented with fever and a new diastolic murmur along the right sternal border. The patient underwent a transthoracic echocardiogram (TTE) which detected an echo-free cavity (asterisks) adjacent to the left sinus of Valsalva, suggestive of a pseudoaneurysm (Figure 1A). A 64-slice multidetector computed tomographic (CT) angiogram was performed to characterize the pseudoaneurysm as well as rule out significant obstructive coronary artery disease in anticipation of open valve surgery. The CT scan identified a 2.5 cm pseudoaneurysm (asterisks) originating from the left sinus of Valsalva (Figures 1B, 2A and 2B). The patient underwent a resection of the AVR and pseudoaneurysm, implantation of a new St. Jude AVR, and closure of the aortic sinus with a bovine pericardial patch. The patient was growing methicillin-resistant Staphylococcus epidermidis on blood cultures. He received intravenous vancomycin for 6 weeks and is doing well 6 months after the surgery. Discussion Although there have been a few published cases of sinus of Valsalva pseudoaneursyms associated with AVR endocarditis, this is the first report correlating TTE-acquired images with images obtained from a 64-slice CT scan.^1,2 As described in this case, CT images can characterize the size and origin of a pseudoaneurysm to direct the approach for surgical intervention. In addition, this case demonstrated that 64-slice CT angiography has the potential to evaluate the coronary arteries prior to open heart surgery and obviate the need to perform a potentially high-risk catheter-directed angiogram in the setting of a sinus of Valsalva pseudoaneurysm.

References

1. Lee TM, Liau CS, Lee YT, Chu SH. Images in cardiovascular medicine. Sinus of Valsalva pseudoaneurysm. Circulation 1998;97:607–608.

2. Katayama Y, Minato N, Sakaguchi M, et al. Surgical treatment of pseudoaneurysm of the sinus of Valsalva after aortic valve replacement for active infective endocarditis. Ann Thorac Cardiovasc Surg 2005;11:419–423.

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From the Division of Cardiology, San Jose Medical Center, Kaiser Permanente, San Jose, California. The authors report no financial relationships or conflicts of interest regarding the content herein. Manuscript submitted September 24, 2009, provisional acceptance given October 19, 2009, final version accepted October 26, 2009. Address for correspondence: James J. Jang, MD, Division of Cardiology, San Jose Medical Center, Kaiser Permanente, 270 International Circle, 2-North, 2nd Floor, San Jose, CA 95119. E-mail: james.j.jang@kp.org