sinus of valsalva aneurysm ( sva ) is a rare cardiac anomaly and is involved in less than 1% of cardiac operations.1 ) most patients with unruptured svas are asymptomatic ; however , a ruptured sva results in a devastating course and causes various clinical manifestations such as aortic regurgitations or arrhythmic disorders .
acute coronary syndrome may occur with compression of the coronary artery2 ) or severe acute aortic regurgitation .
we present a case of a ruptured sva mimicking acute myocardial infarction ( ami ) , without either significant coronary artery compression or aortic regurgitation .
a 39-year - old male patient presented with chest discomfort and dyspnea that had lasted for 12 hours .
a grade 3/6 diastolic murmur was auscultated at the left third intercostal space , and an electrocardiogram showed mild st segment depression on precordial leads ( fig .
the creatine kinase mb ( ck - mb ) , troponin t , and serum creatinine levels were 208.4 ng / ml ( reference value , < 5 ng / ml ) , 2.54 ng / ml ( reference value , < 0.1 ng / ml ) , and 4.1 mg / dl , respectively .
transthoracic echocardiography ( tte ) showed slightly reduced left ventricular systolic function ( ejection fraction , 51% ) with apical akinesia and mild aortic regurgitation ( grade 1 ) .
the pattern of apical akinesia was dissimilar to that associated with the apical ballooning caused by stress - induced cardiomyopathy .
the patient had unstable vital signs , and his echo window was very poor due to severe obesity ; a thorough echocardiographic study was impossible .
emergency coronary angiography was planned under the impression of ami , but cardiac arrest occurred immediately before coronary angiography .
coronary flow was within normal limits , and there was no evidence of plaque disruption or thrombosis .
cardiac catheterization showed elevated right ventricular and pulmonary artery pressure ( peak , 55 mmhg ) .
subsequent transesophageal echocardiography ( tee ) revealed shunted flow from the sva of right coronary cusp to the right atrium and grade 1 aortic regurgitation ( fig .
exposure of the ascending aorta and right atrium revealed a sva on the right coronary cusp , which had ruptured to the right atrium ( fig .
after successful direct closure of the rupture site , intraoperative tee result did not showed shunted flow or aortic valve dysfunction .
preoperative multiple organ failure ( mof ) was aggravated despite intraaortic balloon pump with a high dose of cardiotonics and continuous renal replacement therapy .
electroencephalography showed that severe cerebral injury might have been caused by the prolonged preoperative cpr .
most cases of ami , with svas , are associated with a left sinus origin and compression of the left coronary artery.3 ) another hypothesis is that aortic regurgitation and a left - to - right shunt lead to a severe coronary oxygen supply - demand mismatch , causing myocardial ischemia.4)5 ) in this case , sva originated from the right sinus , and there was neither significant aortic regurgitation nor compression of the coronary artery .
the initial tte study did not yield a correct diagnosis because of a poor echo window and the patient 's lack of cooperation in facilitating a thorough examination .
even with the indefinite findings of the electrocardiogram , primary coronary angiography was mandatory owing to the regional wall motion abnormality and the markedly elevated cardiac enzyme levels .
the possible mechanisms of myocardial infarction , without coronary compression or severe aortic regurgitation , are as follows : acute , severe shunt from the aorta to the right heart causing systemic hypoxia and flow insufficiency to the coronary artery , and decompensation , with left ventricular dysfunction , caused by myocardial infarction - aggravated systemic and myocardial ischemia .
although unruptured svas are mostly asymptomatic , fatal complications such as right ventricular outflow obstruction , malignant arrhythmias , and acute coronary syndrome can occur in ruptured svas .
acute , massive left - to - right shunts can cause myocardial infarction and rapidly progressive mof , without definite obstruction of coronary blood flow or severe aortic regurgitation . with the experience of this case , the possibility of sva rupture should be considered in cases of ami without significant coronary obstruction ; careful echocardiographic evaluation is needed .
 we present a rare case involving a ruptured sinus of valsalva aneurysm ( sva ) and acute myocardial infarction in a 39-year - old male patient . 
 coronary angiography showed normal findings ; however , the patient showed remarkably elevated levels of cardiac enzymes and decreased left ventricular function with apical akinesia on transthoracic echocardiography . 
 transesophageal echocardiography revealed shunt flow from the sva to the right atrium without significant aortic regurgitation . 
 preoperative cardiac arrest was managed by cardiopulmonary resuscitation , and surgical repair was performed by closing the entrance of the aneurysm . 
 however , the compromised hemodynamic status was not reversed by surgery . 
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