Cardiovascular Disease |

Red Herring: Unruptured Sinus of Valsalva Aneurysm Presenting as Hepatobiliary Disease FREE TO VIEW

Gbolahan Ogunbayo, MD; Shanchiya Ravindradas, MD; David Lobo, MD; Dipekka Soni, MD; Seth Jacobson, MD
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Rochester General Hospital, Webster, NY

Chest. 2015;148(4_MeetingAbstracts):76A. doi:10.1378/chest.2251362
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SESSION TITLE: Cardiovascular Disease Student/Resident Case Report Posters

SESSION TYPE: Student/Resident Case Report Poster

PRESENTED ON: Tuesday, October 27, 2015 at 01:30 PM - 02:30 PM

INTRODUCTION: Sinus of Valsalva Aneurysms are rare entities with an incidence of 0.14-0.23%. Unruptured aneurysms are usually innocuous and are usually incidental findings on imaging. We report a case of unruptured SVA causing pseudo tricuspid stenosis whose initial presentation mimicked acute cholecystitis.

CASE PRESENTATION: A 36-year-old male presented to the emergency department with a 12-day history of progressively worsening abdominal pain and shortness of breath with associated sweats, chest heaviness, nausea, vomiting and diarrhea. He denied fevers, chills, rigors or sick contacts. Eleven days before presentation he was admitted for similar symptoms and treated for possible cholecystitis. Physical examination revealed a middle-aged man in respiratory distress with stable vital signs. Significant findings included an elevated JVD, a II/VI systolic and II/VI diastolic murmur, with tender hepatomegaly and guarding over the right upper quadrant. He also had pitting pedal edema. Laboratory tests revealed transaminitis, hyperbilirubinemia, elevated INR, acute kidney injury and elevated lactate. His electrocardiogram was suggestive of right atrial enlargement. A transesophageal echocardiogram confirmed a large saccular aneurysm measuring approximately 4 cm in diameter that impinged on the tricuspid valve causing tricuspid stenosis. Intraoperatively, a cyst was found in the right atrium with a connecting fistula arising from the non-coronary cusp of the aorta that was excised and repaired. The patient had an uneventful post-operative recovery and was discharged seven days after surgery.

DISCUSSION: Although unruptured sinus of valsalva aneurysms are usually asymptomatic, they may present with symptoms of right ventricular outflow tract obstruction. This may cause congestive hepatopathy and mimic a primary hepatobiliary disease as in our patient. A systolic-diastolic thrill, right upper quadrant tenderness and evidence of synthetic liver dysfunction were clues to this uncommon diagnosis.

CONCLUSIONS: Unruptured sinus of valsalva aneurysms may present with signs and symptoms of extra-cardiac disease. A detailed medical history and thorough physical examination is crucial to early diagnosis and appropriate management.

Reference #1: Goldberg N, Krasnow N. Sinus of valsalva aneurysms. Clin Cardiol. 1990;13(12):831-836. doi:10.1002/clc.4960131204.

Reference #2: John S-H. A rare case of unruptured sinus of valsalva aneurysm obstructing the right ventricular outflow tract. J Cardiovasc Ultrasound. 2010;18(2):55-57. doi:10.4250/jcu.2010.18.2.55.

Reference #3: Bricker AO, Avutu B, Mohammed T-LH, et al. Valsalva Sinus Aneurysms: Findings at CT and MR Imaging1. 2010. http://pubs.rsna.org/doi/full/10.1148/rg.301095719. Accessed December 30, 2014.

DISCLOSURE: The following authors have nothing to disclose: Gbolahan Ogunbayo, Shanchiya Ravindradas, David Lobo, Dipekka Soni, Seth Jacobson

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