Traumatic Pseudoaneurysm of the Left Sinus of Valsalva: A Case Report Walid S. Gharzuddine, MBBCh, Jaber I. Sawaya, MD, Hassan K. Kazma, MD, and Mounir Y. Obeid, MD, Beirut, Lebanon
Deceleration injuries o f the aorta result in tears that often lead to exsanguinating hemorrhage. The site is most often at the aortic isthmus, with injuries o f the aortic root being rare. A minority o f patients survive long enough to reach the hospital where p r o m p t diagnosis and treatment are essential for survival. We hereby report on a patient who had a pseudoaneurysm
o f the left sinus o f Valsalva 13 years after a deceleration accident, presumably caused by a contained ntpture o f the aortic root. Transesophageal eeho&ardiography was o f great value in studying the features o f the pseudoaneurysm and its relation to the left main coronary artery and left upper pulmonary vein. (J Am Soc Echocardiogr
T r a u m a t i c pseudoaneurysms o f the aorta usually occur as a complication o f n o n p e n e t r a t i n g trauma or deceleration injuries that allow p r o l o n g e d survival o f the individual. We hereby report an unusual patient w h o survived 12 years after a deceleration injury and was diagnosed by echocardiography. Transesophageal echocardiography allowed adequate delineation o f the pseudoaneurysm and the t h r o m b u s filling it, as well as its relation to the left main c o r o n a r y artery.
sinus of Valsalva lined by a thick layer ofechogenic material (thrombus) that was communicating with the aortic lumen. The aortic valve appeared intact. The patient subsequently underwent a transesophageal study that clearly visualized the pseudoaneurysm and associated thick layer ofthrombus (Figure 1, A). In addition, by slight withdrawal of the probe it was possible to visualize the left main coronary artery as it coursed above the cavity (Figure 1, B). The ostium primum atrial septal defect was seen clearly (Figure 2). A small perimembranous ventricnlar septal defect sealed by aneurysm formation was also discovered. The close association of the left main coronary artery to the pseudoaneurysm was also apparent on angiography (Figure 3). The left upper pulmonalT vein was also seen in proximity to the lateral wall of this pseudoaneurysm (Figure 4). The intimate relation of this pseudoaneurysm to the left main coronary artery and the pulmonau vein, as seen by tranesophagel echocardiography, allowed planning of the surgical procedure whereby a composite graft with reimplantation of the coronary arteries was planned. At surgery, the pseudoaneurysm was found to be adherent to the above-mentioned vessels, with a large pericardial defect posteriorly and dense adhesions between the heart and left lung. It was therefore left in place, excluded from the circulation by the aortic graft. The right coronary artery "was reimplanted, whereas the left main coronary artery was ligated and vein grafts to the left anterior descending and circumflex arteries were placed. The atrial septal defect was also closed.
CASE REPORT History The patient is a 38-year-old man who was referred fbr echocardiography in June 1994 because ofpalpitations and a systolic murmur. Fourteen years ago, at age 25 years, he was involved in an automobile accident and was maintained in an outside hospital in which a chest tube was inserted for significant intrathoracic bleeding. This was a time of war in Lebanon and the chest x-ray films taken could not be located. No other form of imaging was reportedly performed.
Echocardiography Transthoracic echocardiography showed a mildly dilated right ventricle with evidence of an ostium primum atrial septal defect and moderate tricuspid regurgitation. In addition, there was a spheric cavity in the region of the left From the Divisions of Cardiology and Cardiothoracic Surgery, American University of Beirut. Reprint requests: Walid Gharzuddine, MBBCh, American University of Beirut, 850 Third Ave., New York, NY 10022. Copyright © I997 by the American Society of Echocardiography. 0894-7317/97 $5.00 +0 27/4/77485
DISCUSSION The incidence o f high-speed deceleration impact injuries to the heart and great vessels has increased markedly in the era o f the automobile. Disruption o f the thoracic aorta and its branches is a result o f 377
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Figure 1 A, Modified short-axis view at aortic valve level shows pseudoaneurysm and thick layer of thrombus (arrow). B, Left main coronary artery (arrow) visualized at slightly higher level. AO, Aorta; RA, right atrium; LA, left atrium.
differential rates o f deceleration of fixed segment s o f these structures. The most c o m m o n site by far is the aortic isthmus, with rupture at the level o f the sinuses quite rare. A report by Parmley et al. 1 in 1958 states that as many as 80% o f people who suffer such disruption die before reaching' the hospital. O f the survivors, 72% progress to free rupture within 8 days. 1 A small minority survive and have organized hematomas. The survival rate, with rapid transport to the emergency room, prompt diagnosis, and surgical repair, has, in more recent reports, improved this dismal outcome .2 Traumatic pseudoaneurysms may produce compressive symptoms because o f their size but otherwise may remain asymptomatic until a catastrophic rup-
ture occurs or, as could have occurred in this case, an embolus was dislodged. In recent years transesophageal echocardiography is being reported more and more as the optimal screening modality for the evaluation o f patients with suspected blunt injury to the heart and aorta. It has been reported to be more helpful than angiography in delineating intimal tears. 3,4 In addition, it is less invasive and can be performed in the emergency room, intensive care unit, or during surgery. T o our lmowledge, this is the first description o f such a rare complication by transesophageal echocardiograhy. The primum atrial septal defect and membranous ventricular septal defect were coincidental occurrences.
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Figure 2 Short-axis view at aortic valve (AOV) level with left-to-right shunt across ostium primum atrial septal defect.
Figure 3 Aortic root angiogram in right anterior oblique (A) and left anterior oblique (B) projections. Arrow (A) shows calcified thrombus; arrow (B) points to close relation of left main coronary artery to pseudoaneurysm.
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Figure 4 Modified basal short-axis view shows part ofthrombus in wall ofpseudoaneurysm and proximity to left upper pulmonary vein (~rrow). REFERENCES
1. Parmley LF, Mattingly TW, Marion MC, Jahnke EJ. Nonpenetrating injury of the aorta. Circulation !958;17:1086-101. 2. Shorr RM, Crittenden M, Indeck M, Hartunian SL, Rodriguez A. Blunt thoracic trauma: analysisof 515 patients. Ann Surg 1987;206:200-5.
3, Fernandez LG, Lain KY, Messersmith RN, Jairan S, Gordon RT, Shah MR. Transesophagealechocardiography for diagnosing aortic injury: a case report and summary of current imaging techniques. ]"Trauma i994;36:877-80. 4. Shapiro MJ, Yanofslq¢MD, Trapp J, Durham RN, Labovitz A, Sear J, et al. Cardiovascular evaluation in blunt chest trauma using transesophageal echocardiography. J Trauma 1991;31: 835-40.