Ruptured sinus of Valsalva (RSOV) is a rare cardiac anomaly, affecting about 0.09% of the population. Its most common origin is the right coronary or non‑coronary sinus (~97%), while rupture from the left coronary sinus (LCS) accounts for less than 5% of cases [1].

Rupture into left‑sided chambers is even more uncommon: only 4% into the left ventricle (LV) and pericardium in ~1% [2,3]. LCS rupture communicating with the LV is exceptionally rare, with few cases reported in the literature [4,5].

Case Presentation

A 25-year-old previously healthy female presented to the emergency department with sudden-onset breathlessness, hypotension, hypoxia, and bilateral pleural effusion.

Cardiogenic shock was suspected, and initial transthoracic echocardiography suggested ruptured sinus of Valsalva (RSOV). Cardiac CT confirmed a rupture involving the LCC communicating with the LV. (Image 1)

Figure 1. 3D reconstructed CT angiogram showing a saccular RSOV pouch projecting into the left ventricle.

Shortly after admission, the patient suffered a collapse with severe hypotension and required immediate intubation and hemodynamic stabilization. She was taken for emergency surgery.

Intraoperative findings revealed a large RSOV originating from the LCC with direct communication to the LV near the left coronary ostium. The left coronary cusp was significantly damaged and distorted, resulting in moderate to severe aortic regurgitation. (Image 2)

Figure 2. Intraoperative image showing the ruptured sinus of Valsalva near the left coronary cusp.

Given the location and severity of the defect, the surgical team proceeded with:

1. Closure of the RSOV using a Dacron patch (Image 3)
2. Emergency aortic valve replacement using a mechanical prosthesis (Image 4)

The procedure was completed without complications. The patient was transferred to the ICU on minimal inotropes and ventilatory support. She was extubated on postoperative day 2 and discharged on day 08.

Figure 3. Dacron patch repair of the RSOV defect.

Figure 4. Mechanical aortic valve prosthesis implanted after RSOV repair.

Our patient’s RSOV originated from the LCC and communicated directly with the LV, presenting with acute cardiogenic shock and severe aortic regurgitation. In previously reported cases of LCS rupture into LV—with or without associated valve distortion—all required surgical intervention including aortic or double valve replacement [4]. Radhakrishnan et al. described a case of LCS aneurysm bulging into LV with mitral valve distortion, necessitating double valve replacement [3]. A 2018 report described a pseudoaneurysm of the left coronary sinus perforating into LV with severe AR, successfully treated by surgical repair and AVR [5]. Diagnostic imaging—including echocardiography and cardiac CT—is critical for delineation and surgical planning [5]. In our case, CT confirmed the fistulous communication and echocardiography demonstrated valve destruction. Surgical repair of RSOV is generally safe, with favorable long‑term actuarial survival (~84% at 15 years) [6]. Outcomes depend on site of rupture, aortic valve involvement, and intraoperative complications. In our patient, combined patch closure and AVR were essential. Although percutaneous device closure is feasible in select stable patients [7], it is not suitable in patients with hemodynamic instability or valvular destruction as seen here.

This case adds to the limited literature on RSOV originating from the LCC with LV communication. Early diagnosis and emergency surgical management with both patch repair and AVR can be life-saving in hemodynamically unstable patients.

Acknowledgements

We thank the Department of Cardiovascular and Thoracic Surgery, Department of Anesthesiology, Perfusion team, Operation Theatre staff. Special thanks to Dr. Ajit Joshi.

Conflict of Interest

The authors declare no conflict of interest.

Consent

Written informed consent was obtained from the patient for publication of this case report.

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