Role of Transesophageal Echocardiography in Rupture of Sinus of Valsalva Aneurysm with Associated Infective Endocarditis

Introduction: Sinus of Valsalva aneurysm (SOVA) may have associated infective endocarditis in which case single aneurysm may drain into adjacent chamber of heart via multiple openings. We report a rare case of congenital SOVA with associated infective endocarditis where intraoperative transesophageal echocardiogram (TEE) helped in localizing two separate openings in the SOVA draining into right ventricle and an associated perforation in the larger rightward cusp of bicuspid aortic valve (BAV) causing severe aortic regurgitation. Case report: A 28-year-old male presented with grade III to IV dyspnea with previous history of infective endocarditis. Preoperative transthoracic echocardiogram (TTE) showed calcified BAV with severe aortic valve regurgitation and stenosis, severe tricuspid regurgitation, and pulmonary artery hypertension along with ruptured SOVA arising from right coronary sinus and draining into the right ventricle. Intraoperative TEE confirmed the TTE findings and in addition showed the presence of two jets arising from the SOVA draining into right ventricle, a subaortic membrane, and a perforation in the aortic cusp opening into left ventricle. The ruptured SOVA was repaired using single patch technique and aortic valve was replaced. The completeness of the repair was checked using TEE to exclude failure of closure of additional opening if any and the patient was discharged from hospital after 7 days of uneventful postoperative course. Conclusion: Sinus of Valsalva aneurysm may have multiple openings draining into adjacent chamber, particularly if associated with infective endocarditis. Intraoperative TEE plays a crucial role in identification of multiple opening, involvement of adjacent structure, and assessment of completeness of repair.