Aorto-Right Atrial Fistula Resulting From a Ruptured Right Coronary Sinus of Valsalva Aneurysm

A sinus of Valsalva aneurysm (SOVA) is a rare cardiac anomaly characterized by dilation of one of the aortic sinuses, most commonly the right coronary or noncoronary sinus. A SOVA can be clinically silent or present acutely when rupture occurs or more gradually with progressive left-to-right shunting and high-output heart failure. Etiologies of SOVA include congenital failure of the aortic media and annulus to fuse, or an acquired SOVA from endocarditis, trauma, or connective tissue disorders. SOVAs are typically diagnosed by transthoracic echocardiography (TTE), and most patients undergo a surgical approach to treatment. We report a case of a 54-year-old female who presented with chest pain, dyspnea, palpitations, and epistaxis, and was ultimately diagnosed with a ruptured right coronary SOVA forming a fistulous connection to the right atrium. Chest pain, dyspnea, and palpitations were attributed to the ruptured SOVA, whereas the epistaxis was considered incidental. Subsequent transesophageal echocardiography (TEE) revealed a ruptured right coronary SOVA forming a fistulous connection to the right atrium, producing a significant continuous left-to-right shunt with a calculated Qp/Qs of 2.6. She underwent median sternotomy with closure of the aneurysm on the aortic side and additional atrial ligation using a Dacron patch. This case is notable for the patient's atypical demographic profile, the absence of associated anomalies, and the presence of a systolic ejection murmur. It also highlights diagnostic limitations of TTE in this condition, as visualization may be hindered by suboptimal acoustic windows and the complex anatomy of sinus-to-atrial fistulous tracts. Early use of TEE can therefore be critical for accurate diagnosis and timely surgical intervention to prevent hemodynamic deterioration.