Multimodality imaging-guided diagnosis of aortic annular avulsion with right coronary sinus pseudoaneurysm and aorto-left ventricular communication: a case report.

BACKGROUND: Aortic annular avulsion with a right coronary sinus (RCS) pseudoaneurysm is a rare, life-threatening cardiac pathology. Multimodality imaging is crucial for diagnosis and surgical planning.

CASE PRESENTATION: A 42-year-old woman presented with progressive exertional dyspnea following prior coronary angiography (CAG). Transthoracic echocardiogram (TTE) revealed a right coronary sinus pseudoaneurysm and a large interventricular septal dissecting aneurysm (DAIS) communicating with the left ventricular outflow tract (LVOT). Cardiac computed tomography angiography (CCTA) delineated the pseudoaneurysm and its relationship to the coronary arteries, and cardiovascular magnetic resonance (CMR) supported septal myocardial involvement. Transesophageal echocardiogram (TEE) further characterized annular disruption and deformation of the right coronary cusp (RCC). The patient subsequently underwent bovine pericardial patch repair and aortic valve replacement. At the 3-month postoperative follow-up, recovery was favorable, with a left ventricular ejection fraction (LVEF) of 55%; however, pseudoaneurysm recurrence was detected at 6 months. The patient declined reoperation and died 8 months after the initial surgery.

CONCLUSION: We report an exceptionally rare adult case of aortic annular avulsion with a right coronary sinus pseudoaneurysm and aorto-left ventricular communication. Integrated multimodality imaging facilitated diagnostic refinement and guided operative planning, underscoring the need for reinforced root/annular repair and structured mid-term imaging surveillance.