Images in cardiovascular medicine: large unruptured aneurysm in sinus of Valsalva: an unusual cause of right ventricular inflow and outflow tract obstruction.

A 64-year-old man with a large cavitating squamous cell carcinoma (636 cm) in the right lower lobe of the lung was referred for prelobectomy cardiac assessment because of incidental finding of Q waves in leads II, III, and aVF on the ECG. Physical examination revealed an ejection systolic murmur at the left sternal edge. Cardiac size was normal on chest radiograph. A transthoracic echocardiogram revealed a large cavity at the aortic root, 5 cm in diameter, obscuring visualization of the right heart (Figs 1 and 2). Diagnostic cardiac catheterization was performed. An aortogram revealed a large (535 cm), unruptured aneurysm in the sinus of Valsalva arising from the right coronary sinus (Fig 3), and a coronary angiogram showed normal anatomy. A right ventricular angiogram demonstrated obstruction at the inflow and outflow tracts of the right ventricle due to compression from the aneurysm (Fig 4). There was a 20 mm Hg pressure gradient across the right ventricular outflow tract. Therefore, a large, unruptured aneurysm in the sinus of Valsalva may be an unusual cause of right ventricular inflow and outflow tract obstruction.