Sinus of Valsalva Fistula

A 56-year-old man was admitted to the emergency department with effort dyspnea, fatigue and leg edema. The patient had a history of hypertension, diabetes mellitus and left ventricle hypertrophy and no family history of cardiac disease. The patient was fully alert with mild respiratory distress. The physical examination revealed sunken sternum, consistent with pectus ex cavatuma, crackles in the lower parts of the lung, pitting edema and a 3/6 continuous murmur in the left sternal border. The laboratory findings were unremarkable. The patient was treated in the emergency department with sub lingual nitrates and loop diuretics with marked improvement. Transthoracic echocardiography showed severely reduced left ventricle function with estimated ejection fraction of 20% and an echo-lucent tunnel of 6mm with flow from the aortic root to the right atrium (Figure 1). Trans-esophageal echocardiography confirmed the presence of left to right shunting from an aneurysm of the non-coronary cusp of the aortic valve to the right atrium (Figure 2). Cardiac CT and cardiac catheterization provided additional views of the fistula and demonstrated three-vessel coronary artery disease (Figure 3). The patient underwent cardiac surgery. During surgery, an opening measuring 7mm, partially covered with a membrane, was seen on the noncoronary annulus (Figure 4). The patient underwent a direct closure of the fistula with no residual flow in the fistula as observed by intra operative trans-esophageal echocardiography. Three coronary artery bypass grafts were also placed.