Sinus of Valsalva Aneurysm Causing Compression of the Left Anterior Descending Artery Resulting in Angina

Abstract

A 67-year-old man presented with typical crescendo angina and positive results on exercise stress echocardiography suggestive of myocardial ischemia in the left anterior descending coronary artery (LAD) territory with a background of coarctation of the aorta repair at 12 years of age and hypertension. Coronary angiography (Figure 1) suggested that an unruptured left coronary sinus of Valsalva aneurysm (SVA) was causing extrinsic compression of the proximal LAD. This was followed up with computed tomography coronary angiography (Figure 2), which showed a large left SVA measuring approximately 4.2 3.4 cm, displacing the proximal LAD superiorly, causing extrinsic compressive stenosis of >90% with a slitlike lumen. There was also dilation of the non-coronary sinus measuring approximately 2.6 cm projecting inferiorly. The right coronary sinus was not involved. The patient underwent surgery in which the left SVA was visualized to be compressing the LAD against the pulmonary trunk. The aortic valve was bicuspid with fusion between the left and right coronary cusps. Aortic root replacement with a 26-mm Gelweave Valsalva Graft (Vascutek, Renfrewshire, UK) and aortic valve replacement with a 23-mm Carpentier-Edwards Perimount Magna Ease (Edwards Lifesciences, Irvine, California) was performed. The patient had an uncomplicated post-operative course and was asymptomatic on follow-up. SVA is an uncommon pathology that occurs in 0.14% to 0.96% of the population (1).SVA more frequently originates from the right coronary sinus (94%), followed by the noncoronary sinus (5%) and left coronary sinus (1%) (2).There has been association with aortopathies such as coarctation and bicuspid aortic valve and SVA (3). Unruptured SVAs are typically symptom free. Once identified, aggressive surgical approach is vital to prevent rupture, myocardial infarction, or ischemia, which can lead to heart failure or malignant arrhythmias.