An unusual cause of right ventricular failure

A 38-year-old woman presented with worsening shortness of breath (NYHA Class II). Echocardiogram showed a 5.6 cm aneurysm originating from the right sinus of Valsalva (SV) compressing the right ventricular outflow tract. It also revealed right atrial and ventricular dilation, severe tricuspid regurgitation, and moderate pulmonary hypertension. The patient was started on apixaban and diuretics, with surgical repair recommended. This case highlights that unruptured SV aneurysms can cause structural abnormalities and arrhythmias, requiring a broad differential diagnosis for imaging changes. A 38-year-old woman with no significant comorbidities presented with progressive dyspnoea (NYHA Class II) over 6 months, accompanied by a history of pedal oedema and ascites. Initial routine blood tests, including a rapid troponin kit test, were normal; however, n-terminal pro–B-type natriuretic peptide level was elevated (1450 pg/mL). Chest X-ray showed cardiomegaly. Electrocardiography showed a right bundle branch block and ST-segment depression. Echocardiography revealed right atrium (RA) and ventricle (RV) dilation with normal left ventricular function. Severe tricuspid regurgitation and moderate pulmonary arterial hypertension were noted, with an estimated pulmonary artery systolic pressure of approximately 42 mmHg derived from the tricuspid regurgitation jet velocity (see Supplementary material online, Figure S1). The tricuspid annular plane systolic excursion was reduced to 11 mm, consistent with impaired RV function. An aneurysmal sac originating from the right sinus of Valsalva (SV), containing an intramural thrombus and impinging upon the right ventricular outflow tract (RVOT), was identified (Figure 1A; Supplementary material online, Videos S1 and S2). Contrast-enhanced computed tomography, which provides essential anatomical visualization, lesion characterization, and extension assessment, confirmed a large aneurysmal sac (5.6 × 3.3 × 5.9 cm) arising from the right SV, extending towards the RV and compressing the RVOT (Figure 1B). An eccentric, elongated, non-enhancing hypodense area along the aneurysm wall, measuring 4 × 1.5 cm, suggested thrombus. The right coronary artery originated from the aneurysm. The patient was managed with apixaban and diuretics and was advised to undergo aortic root repair, aortic valve replacement, and coronary artery bypass grafting. However, postoperative outcomes are currently unavailable, as the patient opted to pursue surgery at a different centre and has not returned for follow-up. SV aneurysms often remain silent unless rupture occurs; however, unruptured SV aneurysms can also cause structural and electrophysiologic abnormalities, including arrhythmias, heart block, myocardial ischaemia, and (rarely) RVOT obstruction.1,2 Large unruptured SV aneurysms can cause RVOT flow obstruction and tachyarrhythmia.3 This case highlights the need for a broad differential diagnosis when imaging findings and clinical presentation are discordant. Aneurysm of the right sinus of valsalva. (A) Two-dimensional echocardiography. Four-chamber view shows dilated right atrium (RA) and right ventricle (RV); (B) short-axis view showing aneurysmal sac with intramural thrombus; (C) parasternal long-axis view showing aneurysm sac with rent from right sinus of Valsalva. (B) Computed tomography aortogram. (A) Coronal; (B) sagittal; and (C) axial views showing an aneurysm of the right sinus of Valsalva impinging upon the right ventricular outflow tract (arrow, star). Supplementary material is available at European Heart Journal – Case Reports online. The authors would like to sincerely thank the patient for consenting to the publication of this case and for her valuable contribution to medical education and research. Saroj Kumar Sahoo (Conceptualization [lead], Data curation [lead], Investigation [lead], Project administration [lead], Supervision [lead], Visualization [lead], Writing—original draft [lead], Writing—review & editing [lead]), Prabhat Kumar Singh (Investigation [supporting], Supervision [supporting], Visualization [supporting], Writing—original draft [supporting], Writing—review & editing [supporting]), Ramachandra Barik (Investigation [supporting], Supervision [supporting], Visualization [supporting], Writing—original draft [supporting], Writing—review & editing [supporting]), and Sindhu Rao Malla (Investigation [supporting], Supervision [supporting], Visualization [supporting], Writing—original draft [supporting], Writing—review & editing [supporting]) The authors confirm that written consent for submission and publication of this case report, including images and associated text, has been obtained from the patient in line with COPE guidance. The authors have not received any funding for this work. The data underlying this article are available in the article and its online Supplementary material. Further inquiries can be shared on reasonable request to the corresponding author.