A 58-year-old man presented with anterior NSTEMI. Echo showed a large pericardial effusion that was drained and found to be haemorrhagic. Angiography revealed ‘unobstructed’ coronary arteries while contrast enhanced CT showed some extravasation of contrast (Figure A). Cardiovascular magnetic resonance (CMR) was performed visualizing a structure adjacent to the anterior wall. First pass perfusion images of the mass are shown as well as tissue characterization with late enhancement (Figure C, Video 1).
What is the most likely diagnosis?
The correct answer is: c. Ruptured sinus of valsalva aneurysm
First pass perfusion demonstrated its communication with the aortic root but no extravasation of contrast into the pericardial space. There was also a small anterior transmural scar (Figure C, Video 1). During cardiac surgery a small, closed, dimple deep in a recess immediately above the annulus was visualized not needing further intervention (Figure B Follow Up CT arrow). On Follow Up CMR the structure did not show first pass perfusion and appeared to be thrombosed (Figure D, Figure E, Video 2). Diagnosis of a ruptured small aneurysm of the Sinus of Valsalva with extraaortic haematoma probably compromising a small branch coronary artery was made.