Rupture of noncoronary sinus aneurysm into the mitral anterior leaflet and the left ventricle

A 44-year-old man presented with a shortness of breath on exertion for 2 months. His medical history was unremarkable, with no history of previous infection, trauma, or connective tissue diseases. Transthoracic echocardiography revealed a noncoronary sinus of Valsalva aneurysm (SVA) extending downward, entering the anterior mitral valve, traversing the outflow tract of the left ventricle, and compressing the mouth of the aortic valve (Fig. 1). A subsequent CT angiography confirmed a ruptured noncoronary sinus aneurysm mimicking windsock-like protrusion, which communicated with the left ventricle (Fig. 2a, 2b). The patient was scheduled for the surgical repair of the ruptured aneurysm including the ascending aorta, aortic valve and mitral replacement, and closure of fistula towards the left ventricle. A repeat CT angiography after surgery showed satisfactory outcome (Fig. 2c), and the patient was discharged home in good condition with the complete resolution of his symptoms. SVA is a rare cardiac anomaly, which may be congenital in origin or may be associated with trauma, endocarditis, syphilis, or connective tissue diseases. Aneurysms arising from the right coronary sinus are the most common and usually extend and rupture into the right heart chambers, whereas those arising from the noncoronary sinus are less frequent and mostly rupture into the right atrium. Unruptured aneurysms can be incidentally detected using imaging methods, but SVA is generally diagnosed after a rupture, resulting in clinical symptoms, which thereby necessitate an early surgical intervention. The treatment of choice is mainly a surgical approach, although there are also reports about the successful percutaneous closure of ruptured sinus aneurysms using occluder devices