Unusual cause of acute pulmonary edema: unruptured aneurysm of noncoronary sinus causing severe mitral obstruction.

A 54-year-old man presented with a progressive increase in dyspnea for the past 3 years and 1 episode of hemoptysis. On examination, heart rate was 90 beats per minute, and blood pressure was 84/50 mm Hg. On auscultation of heart, a mid-diastolic murmur of grade 3⁄4 was heard at the mitral area. On auscultation of the pulmonary area, a loud pulmonary component of a second heart sound and an ejection systolic murmur of grade 3⁄6 were heard, indicating the presence of pulmonary hypertension. On auscultation of the chest, end inspiratory crepitations were heard at the bilateral basal lung fields. The patient had no history of rheumatic fever. He was treated with oxygen, 5 mg of intravenous morphine, and 20 mg of intravenous furosemide for acute pulmonary edema. Transthoracic echocardiography showed a large mass in the left atrium causing obstruction to the left ventricular inflow. The measured mean transmitral gradient was 13 mm Hg. Transesophageal echocardiography midesophageal long-axis view (109 degrees) showed left atrium occupied by a large mass (5.3 3.8 cm) with spontaneous echo contrast causing severe mitral obstruction (Figures 1 and 2; Movies 1 and 2). Transesophageal echocardiography midesophageal long-axis (139 degrees) and aortic valve short-axis views (45 degrees) showed an aneurysm communicating with the aorta through the noncoronary sinus (Figures 2 and 3; Movies 1 and 3). Transesophageal echocardiography showed that the patient had no aortic regurgitation. A computed tomographic scan