Dynamic aortic regurgitation caused by suction-induced right coronary cusp entrapment in a ruptured right sinus of Valsalva aneurysm: a case report

Background: Aortic regurgitation (AR) is usually caused by intrinsic cusp pathology or aortic root dilatation. Beat-to-beat variability in AR severity, sometimes accentuated by rhythm disturbances, is uncommon and may be overlooked without rhythm-aware, multimodality imaging across multiple cardiac cycles. Case summary: A 30-year-old woman with prior ventricular septal defect repair presented with recurrent palpitations and frequent ventricular premature contractions (PVCs). Transthoracic echocardiography identified a ruptured right sinus of Valsalva aneurysm with intermittent severe AR, more pronounced during premature beats. Three-dimensional transoesophageal echocardiography demonstrated a structurally intact right coronary cusp that was intermittently drawn into the rupture orifice during diastole, consistent with a suction-mediated functional mechanism producing beat-to-beat variation in regurgitation severity. Cardiac computed tomography confirmed rupture morphology and excluded aortic root dilatation. Valve-sparing surgical repair abolished cusp entrapment and restored leaflet coaptation, with mild residual AR on intraoperative assessment. At 2-year follow-up, transthoracic echocardiography showed stable mild AR without progression, and the patient remained asymptomatic. Discussion: This case illustrates a rare functional mechanism of dynamic AR caused by suction-induced cusp entrapment in a ruptured sinus of Valsalva aneurysm and underscores the value of rhythm-aware, stepwise multimodality imaging to guide valve-sparing management when cusp morphology is preserved.