Missed transthoracic echocardiography diagnosis of unruptured sinus of Valsalva aneurysm with thrombus: a case report.

BACKGROUND

Unruptured sinus of Valsalva aneurysm (SVA) is a rare congenital or acquired cardiac lesion. It may remain asymptomatic or present with various clinical manifestations due to its 'mass effect' on the coronary arteries, valves, atria, and other adjacent structures. Unruptured SVA also carries the risk of secondary complications such as infection, thrombosis, and rupture, posing a serious threat to patient health.

CASE SUMMARY: A 55-year-old male from the central region of China, who presented with chest tightness following COVID-19 infection, underwent transthoracic echocardiography (TTE) one year before, which revealed an unruptured non-coronary SVA. Recent follow-up TTE showed findings consistent with the previous examination. Coronary computed tomography angiography (CCTA) subsequently demonstrated a non-coronary SVA complicated by a large thrombus and atherosclerotic changes in the aortic sinus wall. Due to the significant risk of thrombus dislodgement and subsequent systemic embolism, the patient underwent surgical thrombectomy and plasty of the non-coronary SVA. Intraoperative transoesophageal echocardiography (TEE) and surgical exploration confirmed the presence of a mural thrombus; while the potential association between COVID-19 infection and aneurysm formation remains to be fully elucidated. At the 6-month postoperative follow-up, the patient demonstrated favourable physical recovery, with no reported thrombo-embolic events (e.g. stroke or systemic embolism), recurrent symptoms, or other adverse clinical outcomes. A repeat TTE during follow-up revealed a well-preserved aortic root morphology, with normal dimensions and no signs of residual aneurysm or valvular dysfunction.

DISCUSSION: We report a unique instance of a massive thrombosed non-coronary SVA. Considering the limitations of TTE and its low sensitivity to SVA secondary lesions, it is recommended to further perform TEE or CCTA to comprehensively evaluate the morphology and structure of SVA.