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\begin{document}

\title{A giant ascending aortic aneurysm associated with a ruptured sinus of
Valsalva into the right atrium: Role of multimodality imaging}



\author[1]{Mingxing Xie}%
\author[1]{Ziming Zhang}%
\author[1]{Yang Zhao}%
\author[1]{He Li}%
\author[1]{Zhenxing Sun}%
\author[1]{Meng Dai}%
\author[1]{Li Zhang}%
\affil[1]{Huazhong University of Science and Technology Tongji Medical College Department of Pathology}%


\vspace{-1em}



  
  \date{May 19, 2024}


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\selectlanguage{english}
\begin{abstract}
A giant ascending aortic aneurysm associated with a ruptured sinus of
Valsalva is rare. A 53-year-old male patient successfully underwent
Bentall procedure after multimodality imaging which enable the correct
diagnosis to be established and intraoperative transesophageal
echocardiography provides additional information on the surgical
planning.%
\end{abstract}%



\sloppy


\textbf{Introduction}

Giant ascending aortic aneurysm(AAA) is a rarely encountered condition
and only few cases were reported presently1. The most dreadful
complications include dissection and rupture. Conservative management
leads to low life expectancy. Surgical management is recommended in such
cases.We herein report a rare case of giant AAA associated with a
ruptured sinus of Valsalva into the right atrium,which was successfully
treated with open surgical repair.

\textbf{Case Report}

A 53-year-old man was admitted to our hospital for the progressive
enlargement of ascending aortic aneurysm (AAA) during serial follow-up.
His clinical symptoms were intermittent cough and mild exertional
dyspnea.

Chest radiography showed widened mediastinum and increased
cardiothoracic ratio (Fig 1A). Transthoracic echocardiography revealed a
giant AAA(11.3\selectlanguage{ngerman}×9.7cm) with sinotubular junction effacement, compressing
right atrium and tricuspid annulus (Fig 1B-1C). Computed tomography
angiography confirmed the presence of AAA (12.3×11.5cm) (Fig 1D). It
compressed the left and right atrium, and superior vena cava (Fig 1E).
The volume-rendered three-dimensional image showed a huge AAA with a
normal aortic arch and descending aorta (Fig 1F).

Surgical repair of this large AAA was recommended to prevent potentially
life-threatening complications. A detailed transesophageal
echocardiography was done intraoperatively. Apart from the giant AAA,
pre-bypass transesophageal echocardiography revealed a rupture of the
sinus of the Valsalva aneurysm with shunting into the right atrium. (Fig
2A) and bicuspid aortic valve. The rupture in the aneurysmal wall
measuring 0.3cm was shown intuitively by a three-dimensional
echocardiogram (Fig 2B). At operation, a giant AAA occupied almost the
entire pericardial cavity (Fig 2C). The aortic valve was confirmed to
have 2 leaflets, and a ruptured sinus of Valsalva was identified (Fig
2D). The patient underwent a successful Bentall procedure and the repair
of a ruptured sinus of Valsalva. Weaning from cardiopulmonary bypass and
postoperative course were uneventful\selectlanguage{english},The patient was discharged from
the hospital 10 days after surgery.

\textbf{Discussion}

A giant AAA is a rare disease which is defined as an aneurysm more than
10 cm in diameter 2. The AAA's size, rapid expansion, and calcification
are associated with an increased risk of rupture3. To our knowledge, a
giant AAA associated with a ruptured sinus of Valsalva into the right
atrium has not been reported previously. Transthoracic echocardiography
is the first-line imaging modality in detecting proximal ascending
aortic structure. Computed tomography angiography and magnetic resonance
angiography have nowadays become commonly used imaging modalities in
confirming the diagnosis of AAA and precise its dimensions.
Intraoperative transesophageal echocardiography is a versatile
diagnostic and monitoring tool to assist with surgical decision-making
in the operating room4. In our case, transthoracic echocardiography and
computed tomography angiography failed to detect the rupture in the
sinus of the Valsalva aneurysm. Intraoperative transesophageal
echocardiography provides additional information to the surgical team
and assists in adjusting the surgical plan. Our case highlights that
multimodality imaging plays a paramount role in making a definite
diagnosis of a giant AAA associated with a ruptured sinus of Valsalva
into the right atrium.

\textbf{Conflicts of interest:} None declared.

\textbf{Informed consent:} Informed consent was given by the patient.

1. Shah P, Gupta N, Goldfarb I, Shamoon F. Giant dissecting aortic
aneurysm in an asymptomatic young male. Case Rep Vasc Med.
2015;2015:958464

2. Agarwal V, Yaliwal C, Ofo E, Kolvekar S. Giant ascending aortic
aneurysm--a case report and review. Heart Lung Circ. 2007;16:385-388

3. Bicer M, Yuksel A, Kan II. The largest reported giant ascending
aortic aneurysm presented with superior vena cava syndrome. Braz J
Cardiovasc Surg. 2020;35:834-837

4. Nicoara A, Skubas N, Ad N, Finley A, Hahn RT, Mahmood F, et al.
Guidelines for the use of transesophageal echocardiography to assist
with surgical decision-making in the operating room: A surgery-based
approach: From the american society of echocardiography in collaboration
with the society of cardiovascular anesthesiologists and the society of
thoracic surgeons. J Am Soc Echocardiogr. 2020;33:692-734

\textbf{Figures Legend:}

\textbf{Figure1}

Chest radiography showing widened mediastinum (A); TTE showing the giant
AAA(11.3x9.75cm) with sinotubular junction effacement (B); TTE
demonstrating the giant AAA compressed left atrium, right atrium, and
tricuspid annulus (C); Contrast-enhanced computed tomography revealing
ascending aortic aneurysm compressing the left atrium, right atrium,
superior vena cava, (D and E); The 3-dimensional computed tomography
showing a giant AAA, normal aortic arch, and descending aorta(F)\selectlanguage{english}
\begin{figure}[H]
\begin{center}
\includegraphics[width=0.70\columnwidth]{figures/image1/image1}

\end{center}
\end{figure}

\textbf{Figure2}

Transesophageal echocardiography and 3-dimensional transesophageal
echocardiography demonstrating an orifice in the sinus of the Valsalva
aneurysm communicating with the right atrium (A and B); Intraoperative
photo revealing the giant ascending aortic aneurysm (C); Intraoperative
photo displaying the orifice in the aneurysmal wall (white arrow; D)\selectlanguage{english}
\begin{figure}[H]
\begin{center}
\includegraphics[width=0.70\columnwidth]{figures/image2/image2}

\end{center}
\end{figure}

\selectlanguage{english}
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