Early diagnosis and Surgical Management of a Ruptured Sinus of Valsalva Aneurysm: A Case report

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Desai, Parth Bharat Solanki, Hitendra Kanzaria, Ekta Rathod, and 2 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7261371/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background Ruptured Sinus of Valsalva aneurysm (RSOVA) is a rare and fatal cardiac condition characterized by an abnormal outpouching of the aortic root that ruptures into adjacent cardiac chambers typically the right atrium (RA) or right ventricle (RV). Due to its asymptomatic presentation, it often poses diagnostic and therapeutic challenges. We report this case to highlight role of early diagnosis, multimodal imaging and timely surgical intervention in improving outcomes. Case presentation: A 33-year-old hypertensive man presented with epigastric pain, abdominal discomfort, fatigue with weakness, breathlessness corresponding to New York Heart Association (NYHA) Grade II, pedal edema, palpitations, and signs of heart failure. Clinical examination revealed a bounding pulse, elevated jugular venous pressure, and a continuous murmur. 2D Echo, Cardiac MSCT + Aortogram, HRCT chest confirmed a RSOVA originating from the right coronary cusp (RCC) into RA, with severe aortic regurgitation (AR), severe mitral (MR) and tricuspid regurgitation (TR), and left ventricular systolic dysfunction. RSOV repair was done through sternotomy, excision of the aneurysmal sac and closure with a polytetrafluoroethylene (PTFE) patch. Postoperative management included antibiotics, cardiovascular medications, and diuretics. Follow-up echocardiography demonstrated successful repair without residual shunting, though moderate mitral regurgitation and ventricular dysfunction persisted. Conclusion A thorough clinical history, physical examination, timely diagnostic approach and personalized operative and treatment regimen is the cornerstone of the case. This report underscores the need for awareness of this asymptomatic rare condition and benefit of comprehensive individualized approach. Ruptured Sinus of Valsalva Aneurysm (RSOV) Aortic Regurgitation Heart Failure Surgical Repair Echocardiography Multimodal Imaging Cardiac surgery Figures Figure 1 Figure 2 Figure 3 INTRODUCTION Sinus of Valsalva (SOV) are the small outpouching in the root of aorta located between aortic valve annulus and sinotubular junction that occur at elastic lamina [ 1 ]. When there is intracardiac course, it might protrude into pericardial space that is called RSOV. This may rupture into right and rarely left heart chambers to form an aorta – cardiac fistula. It is typically caused by an aortic media defect i.e. enlargement in the root of aorta, with accompanying abnormalities such as aortic regurgitation or a ventricular septal defect [ 2 ]. Causes include congenital diseases, such as Marfan syndrome and ventricular septal defect (VSD), and acquired diseases, such as infective endocarditis. The congenital aneurysms are thought to result from congenital absence of elastic and muscular tissue in the wall of the SOV [ 1 ]. The aneurysm compress a nearby heart chamber and blood vessel of the heart this can reduce the blood supply to the heart muscle or produce electrical conduction defects. Symptoms after rupture are breathlessness, chest pain and fatigue progressing to heart failure. Ruptures can rarely happen to the pericardium, pulmonary artery, superior vena cava, and left heart chambers [ 3 ]. When RSOV occurs in the right ventricle, a persistent murmur with diastolic enhancement is the typical clinical feature. The diastolic enhancement of the murmur is brought on by the compression of the aneurysm track through the right ventricular wall during systole and improved flow during diastole. Left-sided ruptures typically produce isolated diastolic murmurs [ 4 ]. RSOV can be diagnosed by a transoesophageal echocardiogram (TEE). Magnetic resonance imaging (MRI) and CT scan are other subsidiary tests. Coronary angiography may be done in preparation for surgery [ 2 ]. In RSOV repair surgery aneurysmal sac is removed, and the defect repaired either by direct stitches or patch closure. Sometimes an aortic valve replacement is necessary. Device closure of RSOV is another option being increasingly used in suitable cases [ 4 ]. The most frequent consequence is spontaneous rupture, and patients with burst aneurysms typically experience congestive cardiac failure. RSOVA has a poor prognosis. It should be suspected whenever a continuous murmur is detected on auscultation. CASE PRESESNTATION A 33-year-old man nondiabetic, hypertensive presented with chief complaint of epigastric pain, abdominal discomfort, breathing difficulty (New York Heart Association (NYHA) Grade – II) with generalized weakness and had history of pedal edema, palpitations, dizziness for past 2 months along with chest pain and signs of heart failure. He had no history of alcohol, smoking, tobacco consumption, or any cardiac interventions. On examination blood pressure was 134/40mmHg and pulse rate was 140/min and hyperdynamic. The pulse exhibited a bounding quality with a “water hammer pulse observed”. The jugular venous pressure was elevated – 8cm above sternal angle. The arm span to height ratio was less than 1. General examination revealed parasternal heave, pansystolic murmur, Apex impulse visible, Apex beats palpable and on auscultation a continuous murmur was observed. His N- terminal -pro- hormone B – type natriuretic peptide (NTProBNP) level was 2660.0 pg/mL. On auscultation of the chest, S1 and S2 were both normally split with the loud P2 component. The lower left sternal edge was the site of a high-pitched, grade 4/6, the murmur peaked during systole and intensified with forward-leaning and handgrip. The Chest X-ray showed Cardiomegaly with prominent bronchovascular marking in bilateral lung filed. 2D Echo showed a ruptured and aneurysmal SOV (connecting the RCC to the RA, Ruptured into RA), neck of aneurysm: 2cm, total dimension of aneurysm: 2 × 4.6 cm. Severe AR, dilated left atrium (LA), left ventricle (LV), RA & RV in size with normal RV function. There was also global LV hyperkinesia with mild systolic dysfunction and severe mitral regurgitation along with severe TR and mild pulmonary arterial hypertension (PAH). Additionally, concentric left ventricular hypertrophy (LVH+) was noted alongside Grade II left ventricle diastolic dysfunction, LVEF-55%. (Fig:1) Cardiac MSCT + Aortogram showed out pouching from right coronary sinus (above aortic annulus level) projecting inferiorly and towards right side with large SOV aneurysm . Size of aneurysm: 50 × 30 × 27 mm (TR × CC× AP) and neck of aneurysm: 13 × 13 mm (AP × CC). The aneurysm sac bulges toward the RA with small 4mm size contrast jet visible into right atrium at its apex suggestive of rupture and confirmed the diagnosis of a RSOV aneurysm into the RA with no evidence of co-arctation, intramural hematoma, mural thrombi or dissection ( fig:2 ) HRCT CHEST REPORT revealed multifocal well demarcated areas of hyper attenuation with areas of hypoattenuation seen in bilateral lung parenchyma more predominant in right upper and bilateral lower lobes giving rise to mosaic pattern of attenuation. Diffuse cardiomegaly noted. Both right and left pulmonary arteries are also dilated (23mm and 24mm, respectively). Few areas of smooth interstitial septal thickening in bilateral lower lungs. Pulmonary congestion noted. Additionally, multiple small, non-specific lymph nodes are present in the mediastinum. Bilateral carotid doppler showed normal lumen no thrombosis. A midline sternotomy was performed to gain access to the thoracic cavity. Cardiopulmonary bypass (CPB) was instituted, and moderate hypothermia was maintained throughout the procedure. Cardiac arrest was achieved using Del Nido cold cardioplegia. The superior vena cava (SVC) and inferior vena cava (IVC) were snared to ensure vascular control. An oblique incision was made in the right atrium, allowing for the excision of the sinus sac. The resulting aperture was meticulously closed in three layers and reinforced with a PTFE patch using 4 − 0 Prolene sutures. The integrity of the repair was assessed before closing the right atrium in two layers with 6 − 0 Prolene sutures. Deairing was carefully performed before releasing the aortic cross-clamp. The patient was successfully weaned off CPB, demonstrating stable hemodynamics in sinus rhythm without the need for inotropic support. Hemostasis was thoroughly checked, and the chest was closed in a routine manner (Fig:3). Closure detail A 32F mediastinal drain was placed for postoperative drainage. The sternum was secured using six No. 6 stainless steel wires. Soft tissue closure was performed using a continuous 1 − 0 Vicryl suture, and the skin incision was closed with a continuous 3 − 0 Monocryl suture. RSOV between RCC and RA was repaired surgically and further intraoperative findings revealed large sinus at the base of RCC and communicating & Opening in RA. At this time, proper surgery is the only necessitated surgical treatment for Ruptured and aneurysmal SOV. Postoperatively, the patient received a below mentioned comprehensive care regimen. Treatment during Hospitalization : Sr. No. Drug - Generic Name Route Dosage Frequency Indication Duration 1. Inj. Ceftriaxone Intravenous 1gm 1-0-1 Antibiotic 7 days 2. Tab. Metoprolol Succinate Oral 25mg 1-0-0 Beta-blocker Antihypertensive 9 days 3. Tab. Spironolactone Oral 25gm 1-1-0 Potassium sparing diuretic 11 days 4. Tab. Spironolactone + Furosemide Oral 50mg + 20mg 1- ½ − 0 Combination of Spironolactone and Furosemide. It is used in the treatment of oedema 7 days 5. Tab. Ramipril Oral 1.25mg 1-0-1 Angiotensin Converting Enzyme (ACE) inhibitor. 12 days 6. Tab. Pantoprazole Oral 40mg 1-0-1 Proton Pump Inhibitor 7 days 7. Tab. Acebrophylline Oral 200mg 1-0-0 Mucolytic and Bronchodilator 7 days Discharge Treatment : Sr. No. Drug - Generic Name Route Dosage Frequency Indication Duration 1. Tab. Amoxycillin + Clavulanic acid Oral 500mg + 125mg 1-0-1 Antibiotic 7 days 2. Tab. Aspirin Oral 75mg 0-1-0 Antiplatelet 7 days 3. Tab. Spironolactone Oral 25gm 1-1-0 Potassium sparing diuretic 11 days 4. Tab. Spironolactone + Furosemide Oral 50mg + 20mg 1- ½ − 0 Combination of Spironolactone and Furosemide. It is used in the treatment of oedema 7 days 5. Tab. Ramipril Oral 1.25mg 1-0-1 Angiotensin Converting Enzyme (ACE) inhibitor. 12 days 6. Tab. Pantoprazole Oral 40mg 1-0-1 Proton Pump Inhibitor 7 days 7. Tab. Acebrophylline Oral 200mg 1-0-0 Mucolytic and Bronchodilator 7 days Post -operative TEE findings: No flow across through repaired RSOV to RA. No AR, MR and TR with mild PAH after RSOV repaired. Post op 2D ECHO s/p RSOV Repair, Global LV Hypokinesia, LVEF 35%, Dilated LV Size with Severe LV Systolic Dysfunction. Moderate MR. Dilated RA and RV in size with RV. Dysfunction. Mild TR with Mild PAH. Grade III LV D/D. During 1 month follow-up there was no further complications or adverse events reported. DISCUSSION Edwards first described SOV aneurysm as resulting from a deficiency of normal elastic tissue in the medial layer of the aortic sinus, this weakness leads to the formation of a saccular aneurysm, which gradually enlarges under high pressure and eventually ruptures [ 5 ]. RSOV is a rare but life-threatening cardiac anomaly caused by congenital weakness or acquired infections such as infective endocarditis. It commonly arises from the right coronary sinus and most frequently ruptures into right heart chambers, leading to symptoms such as breathlessness, chest pain, and heart failure [ 6 ]. In this case, the patient presented with epigastric pain, abdominal discomfort which is rare, dyspnea, generalized weakness, pedal edema, and palpitations, consistent with RSOV's clinical manifestations. A continuous murmur with diastolic enhancement, a hallmark auscultatory feature, was detected. This describes the diastolic murmur's enhancement due to compression of the aneurysm track through the right ventricular wall during systole and improved flow during diastole. Diagnosis of RSOV relies on multimodal imaging, including echocardiography, cardiac MSCT, and aortography. The patient’s imaging findings revealed a large RSOV aneurysm originating from the RCC, rupturing into the RA, with associated severe aortic regurgitation, ventricular dilation, and valvular dysfunction. These findings are consistent with documented RSOV cases, where aneurysm rupture into right heart chambers leads to hemodynamic instability and valvular involvement. Surgical intervention remains the definitive treatment, with repair involving aneurysm excision and defect closure using a PTFE patch. The patient underwent a standard repair via sternotomy, CPB, and PTFE patch closure. Postoperatively, TEE was normal & structured pharmacological management included antibiotics, beta-blockers, ACE inhibitors, and diuretics to prevent infection, stabilize hemodynamic, and manage fluid overload. These measures align with recommended postoperative care strategies to optimize recovery and prevent complications. CONCLUSION Physical examination include continuous murmur is significant and must lead towards multimodal individualized diagnostic approach i.e. echocardiography, cardiac MSCT, aortography, HRCT chest, TEE and cardiac biomarker for accurate diagnosis along with personalized surgical planning and treatment regimen in RSOV. From this case 2D Echo, cardiac MSCT + aortography, HRCT chest played a key role to investigate RSOV and early repair with aneurysm excision and PTFE patch closure retored structural integrity and hemodynamic stability preventing further complications. Abbreviations ACE Angiotensin Converting Enzyme AR Aortic Regurgitation CPB Cardiopulmonary bypass HRCT High-Resolution Computed Tomography IVC Inferior Vena Cava LA Left Atrium LV Left Ventricle LVH Left Ventricular Hypertrophy MRI Magnetic resonance imaging MSCT Multi-Slice Computed Tomography PTFE Polytetrafluoroethylene PAH Pulmonary Arterial Hypertension RA Right Atrium RCC Right Coronary Cusp RV Right Ventricle RSOV Rupture of sinus of Valsalva aneurysm SOV Sinus of Valsalva SVC Superior Vena Cava TEE Transoesophageal Echocardiogram TR Tricuspid Regurgitation NTProBNP N-terminal-pro-hormone B-type natriuretic peptide NYHA New York Heart Association VSD Ventricular Septal Defect Declarations Ethics approval and consent to participate: Not applicable Consent for publication: Written informed consent was obtained from the patient’s relatives for the publication of this case report and accompanying images. Data availability: No datasets were generated or analysed during the current study. Competing interest: The authors declare that they have no competing interest. Funding: There is no source of funding. Author’s contribution: HJ-corresponding author and manuscript writing, MRD-acquisition and interpretation of data, manuscript writing, PBS- Conception of the work, acquisition of data, manuscript editing, HK- design of work, acquisition of data, manuscript editing, ER- Analysis of data, manuscript editing, MMR- analysis of data, manuscript editing and revising it. All the authors read and approved the final manuscript. Acknowledgement: None References Sari, N. M. A. W., Dewangga, M. S. Y., Wibhuti, I. B. R., Suastika, L. O. S., Badung, I. D. G. S. M., de Liyis, B. G., Kosasih, A. M., & Prana Jagannatha, G. N. (2023). Ruptured sinus of Valsalva aneurysm coexisted with congenital ventricular septal defect: a case series. The Egyptian Heart Journal : (EHJ) : Official Bulletin of the Egyptian Society of Cardiology , 75 (1), 90. https://doi.org/10.1186/s43044-023-00420-y Weinreich, M., Yu, P.-J., & Trost, B. (2015). Sinus of valsalva aneurysms: review of the literature and an update on management: Sinus of valsalva aneurysm. Clinical Cardiology , 38 (3), 185–189. https://doi.org/10.1002/clc.22359. Post MC, Braam RL, Groenemeijer BE, Nicastia D, Rensing BJ, Schepens MA. Rupture of right coronary sinus of Valsalva aneurysm into right ventricle. Neth Heart J [Internet]. 2010;18(4):209–11. Available from: http://dx.doi.org/10.1007/bf03091763 Johnsonfrancis.org. [cited 2024 Aug 26]. Available from: https://johnsonfrancis.org/professional/rupture-of-sinus-of-valsalva-aneurysm-rsov/ Edwards, J. E., & Burchell, H. B. (1957). The pathological anatomy of deficiencies between the aortic root and the heart, including aortic sinus aneurysms. Thorax , 12 (2), 125–139. https://doi.org/10.1136/thx.12.2.125 Yan, F., Abudureheman, M., Huo, Q., Shabiti, A., Zhu, T., & Liu, Z. (2014). Surgery for sinus of Valsalva aneurysm: 33-year of a single center experience. Chinese Medical Journal , 127 (23), 4066–4070. https://doi.org/10.3760/cma.j.issn.0366-6999.20140715 Additional Declarations No competing interests reported. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-7261371","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Case Report","associatedPublications":[],"authors":[{"id":504663217,"identity":"8994ca44-e56a-4d53-90a0-6287e306c4cd","order_by":0,"name":"Margi R. 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When there is intracardiac course, it might protrude into pericardial space that is called RSOV. This may rupture into right and rarely left heart chambers to form an aorta – cardiac fistula. It is typically caused by an aortic media defect i.e. enlargement in the root of aorta, with accompanying abnormalities such as aortic regurgitation or a ventricular septal defect [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. Causes include congenital diseases, such as Marfan syndrome and ventricular septal defect (VSD), and acquired diseases, such as infective endocarditis. The congenital aneurysms are thought to result from congenital absence of elastic and muscular tissue in the wall of the SOV [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. The aneurysm compress a nearby heart chamber and blood vessel of the heart this can reduce the blood supply to the heart muscle or produce electrical conduction defects. Symptoms after rupture are breathlessness, chest pain and fatigue progressing to heart failure. Ruptures can rarely happen to the pericardium, pulmonary artery, superior vena cava, and left heart chambers [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. When RSOV occurs in the right ventricle, a persistent murmur with diastolic enhancement is the typical clinical feature. The diastolic enhancement of the murmur is brought on by the compression of the aneurysm track through the right ventricular wall during systole and improved flow during diastole. Left-sided ruptures typically produce isolated diastolic murmurs [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. RSOV can be diagnosed by a transoesophageal echocardiogram (TEE). Magnetic resonance imaging (MRI) and CT scan are other subsidiary tests. Coronary angiography may be done in preparation for surgery [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. In RSOV repair surgery aneurysmal sac is removed, and the defect repaired either by direct stitches or patch closure. Sometimes an aortic valve replacement is necessary. Device closure of RSOV is another option being increasingly used in suitable cases [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. The most frequent consequence is spontaneous rupture, and patients with burst aneurysms typically experience congestive cardiac failure. RSOVA has a poor prognosis. It should be suspected whenever a continuous murmur is detected on auscultation.\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003e\u003c/p\u003e"},{"header":"CASE PRESESNTATION","content":"\u003cp\u003eA 33-year-old man nondiabetic, hypertensive presented with chief complaint of epigastric pain, abdominal discomfort, breathing difficulty (New York Heart Association (NYHA) Grade – II) with generalized weakness and had history of pedal edema, palpitations, dizziness for past 2 months along with chest pain and signs of heart failure. He had no history of alcohol, smoking, tobacco consumption, or any cardiac interventions. On examination blood pressure was 134/40mmHg and pulse rate was 140/min and hyperdynamic. The pulse exhibited a bounding quality with a “water hammer pulse observed”. The jugular venous pressure was elevated – 8cm above sternal angle. The arm span to height ratio was less than 1. General examination revealed parasternal heave, pansystolic murmur, Apex impulse visible, Apex beats palpable and on auscultation a continuous murmur was observed. His N- terminal -pro- hormone B – type natriuretic peptide (NTProBNP) level was 2660.0 pg/mL. On auscultation of the chest, S1 and S2 were both normally split with the loud P2 component. The lower left sternal edge was the site of a high-pitched, grade 4/6, the murmur peaked during systole and intensified with forward-leaning and handgrip.\u003c/p\u003e\u003cp\u003eThe Chest X-ray showed Cardiomegaly with prominent bronchovascular marking in bilateral lung filed. 2D Echo showed a ruptured and aneurysmal SOV (connecting the RCC to the RA, Ruptured into RA), neck of aneurysm: 2cm, total dimension of aneurysm: 2 × 4.6 cm. Severe AR, dilated left atrium (LA), left ventricle (LV), RA \u0026amp; RV in size with normal RV function. There was also global LV hyperkinesia with mild systolic dysfunction and severe mitral regurgitation along with severe TR and mild pulmonary arterial hypertension (PAH). Additionally, concentric left ventricular hypertrophy (LVH+) was noted alongside Grade II left ventricle diastolic dysfunction, LVEF-55%. \u003cb\u003e(Fig:1)\u003c/b\u003e\u003c/p\u003e\u003cp\u003eCardiac MSCT + Aortogram showed out pouching from right coronary sinus (above aortic annulus level) projecting inferiorly and towards right side with large \u003cem\u003eSOV aneurysm\u003c/em\u003e. Size of aneurysm: 50 × 30 × 27 mm (TR × CC× AP) and neck of aneurysm: 13 × 13 mm (AP × CC). The aneurysm sac bulges toward the RA with small 4mm size contrast jet visible into right atrium at its apex suggestive of rupture and confirmed the diagnosis of a RSOV aneurysm into the RA with no evidence of co-arctation, intramural hematoma, mural thrombi or dissection (\u003cem\u003efig:2\u003c/em\u003e)\u003c/p\u003e\u003cp\u003eHRCT CHEST REPORT revealed multifocal well demarcated areas of hyper attenuation with areas of hypoattenuation seen in bilateral lung parenchyma more predominant in right upper and bilateral lower lobes giving rise to mosaic pattern of attenuation. Diffuse cardiomegaly noted. Both right and left pulmonary arteries are also dilated (23mm and 24mm, respectively). Few areas of smooth interstitial septal thickening in bilateral lower lungs. Pulmonary congestion noted. Additionally, multiple small, non-specific lymph nodes are present in the mediastinum. Bilateral carotid doppler showed normal lumen no thrombosis.\u003c/p\u003e\u003cp\u003eA midline sternotomy was performed to gain access to the thoracic cavity. Cardiopulmonary bypass (CPB) was instituted, and moderate hypothermia was maintained throughout the procedure. Cardiac arrest was achieved using Del Nido cold cardioplegia. The superior vena cava (SVC) and inferior vena cava (IVC) were snared to ensure vascular control. An oblique incision was made in the right atrium, allowing for the excision of the sinus sac. The resulting aperture was meticulously closed in three layers and reinforced with a PTFE patch using 4 − 0 Prolene sutures. The integrity of the repair was assessed before closing the right atrium in two layers with 6 − 0 Prolene sutures. Deairing was carefully performed before releasing the aortic cross-clamp. The patient was successfully weaned off CPB, demonstrating stable hemodynamics in sinus rhythm without the need for inotropic support. Hemostasis was thoroughly checked, and the chest was closed in a routine manner \u003cb\u003e(Fig:3).\u003c/b\u003e\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eClosure detail\u003c/strong\u003e\u003c/p\u003e\u003cp\u003eA 32F mediastinal drain was placed for postoperative drainage. The sternum was secured using six No. 6 stainless steel wires. Soft tissue closure was performed using a continuous 1 − 0 Vicryl suture, and the skin incision was closed with a continuous 3 − 0 Monocryl suture. RSOV between RCC and RA was repaired surgically and further intraoperative findings revealed large sinus at the base of RCC and communicating \u0026amp; Opening in RA.\u003c/p\u003e\u003cp\u003eAt this time, proper surgery is the only necessitated surgical treatment for Ruptured and aneurysmal SOV. Postoperatively, the patient received a below mentioned comprehensive care regimen.\u003c/p\u003e\u003cp\u003e\u003cb\u003eTreatment during Hospitalization\u003c/b\u003e:\u003c/p\u003e\u003cdiv class=\"gridtable\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\"−\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e\u003ctable float=\"No\" id=\"Taba\" border=\"1\"\u003e\u003ccolgroup cols=\"7\"\u003e\u003c/colgroup\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSr. No.\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eDrug - Generic Name\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eRoute\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eDosage\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003eFrequency\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c6\"\u003e\u003cp\u003eIndication\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c7\"\u003e\u003cp\u003eDuration\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003e1.\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eInj. Ceftriaxone\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eIntravenous\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e1gm\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"−\" colname=\"c5\"\u003e\u003cp\u003e1-0-1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003eAntibiotic\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e7 days\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003e2.\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eTab. Metoprolol Succinate\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eOral\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e25mg\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"−\" colname=\"c5\"\u003e\u003cp\u003e1-0-0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003eBeta-blocker Antihypertensive\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e9 days\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003e3.\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eTab. Spironolactone\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eOral\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e25gm\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"−\" colname=\"c5\"\u003e\u003cp\u003e1-1-0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003ePotassium sparing diuretic\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e11 days\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003e4.\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eTab. Spironolactone + Furosemide\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eOral\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e50mg + 20mg\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"−\" colname=\"c5\"\u003e\u003cp\u003e1- ½ − 0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003eCombination of Spironolactone and Furosemide. It is used in the treatment of oedema\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e7 days\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003e5.\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eTab. Ramipril\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eOral\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e1.25mg\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"−\" colname=\"c5\"\u003e\u003cp\u003e1-0-1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003eAngiotensin Converting Enzyme (ACE) inhibitor.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e12 days\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003e6.\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eTab. Pantoprazole\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eOral\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e40mg\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"−\" colname=\"c5\"\u003e\u003cp\u003e1-0-1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003eProton Pump Inhibitor\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e7 days\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003e7.\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eTab. Acebrophylline\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eOral\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e200mg\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"−\" colname=\"c5\"\u003e\u003cp\u003e1-0-0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003eMucolytic and Bronchodilator\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e7 days\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/table\u003e\u003c/div\u003e\u003cp\u003e\u003cb\u003eDischarge Treatment\u003c/b\u003e:\u003c/p\u003e\u003cdiv class=\"gridtable\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\"−\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e\u003ctable float=\"No\" id=\"Tabb\" border=\"1\"\u003e\u003ccolgroup cols=\"7\"\u003e\u003c/colgroup\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSr. No.\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eDrug - Generic Name\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eRoute\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eDosage\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003eFrequency\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c6\"\u003e\u003cp\u003eIndication\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c7\"\u003e\u003cp\u003eDuration\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003e1.\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eTab. Amoxycillin + Clavulanic acid\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eOral\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e500mg + 125mg\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"−\" colname=\"c5\"\u003e\u003cp\u003e1-0-1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003eAntibiotic\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e7 days\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003e2.\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eTab. Aspirin\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eOral\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e75mg\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"−\" colname=\"c5\"\u003e\u003cp\u003e0-1-0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003eAntiplatelet\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e7 days\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003e3.\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eTab. Spironolactone\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eOral\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e25gm\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"−\" colname=\"c5\"\u003e\u003cp\u003e1-1-0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003ePotassium sparing diuretic\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e11 days\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003e4.\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eTab. Spironolactone + Furosemide\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eOral\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e50mg + 20mg\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"−\" colname=\"c5\"\u003e\u003cp\u003e1- ½ − 0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003eCombination of Spironolactone and Furosemide. It is used in the treatment of oedema\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e7 days\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003e5.\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eTab. Ramipril\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eOral\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e1.25mg\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"−\" colname=\"c5\"\u003e\u003cp\u003e1-0-1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003eAngiotensin Converting Enzyme (ACE) inhibitor.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e12 days\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003e6.\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eTab. Pantoprazole\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eOral\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e40mg\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"−\" colname=\"c5\"\u003e\u003cp\u003e1-0-1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003eProton Pump Inhibitor\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e7 days\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003e7.\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eTab. Acebrophylline\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eOral\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e200mg\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"−\" colname=\"c5\"\u003e\u003cp\u003e1-0-0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003eMucolytic and Bronchodilator\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e7 days\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/table\u003e\u003c/div\u003e\u003cp\u003ePost -operative TEE findings: No flow across through repaired RSOV to RA. No AR, MR and TR with mild PAH after RSOV repaired. Post op 2D ECHO s/p RSOV Repair, Global LV Hypokinesia, LVEF 35%, Dilated LV Size with Severe LV Systolic Dysfunction. Moderate MR. Dilated RA and RV in size with RV. Dysfunction. Mild TR with Mild PAH. Grade III LV D/D. During 1 month follow-up there was no further complications or adverse events reported.\u003c/p\u003e"},{"header":"DISCUSSION","content":"\u003cp\u003eEdwards first described SOV aneurysm as resulting from a deficiency of normal elastic tissue in the medial layer of the aortic sinus, this weakness leads to the formation of a saccular aneurysm, which gradually enlarges under high pressure and eventually ruptures [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. RSOV is a rare but life-threatening cardiac anomaly caused by congenital weakness or acquired infections such as infective endocarditis. It commonly arises from the right coronary sinus and most frequently ruptures into right heart chambers, leading to symptoms such as breathlessness, chest pain, and heart failure [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. In this case, the patient presented with epigastric pain, abdominal discomfort which is rare, dyspnea, generalized weakness, pedal edema, and palpitations, consistent with RSOV's clinical manifestations. A continuous murmur with diastolic enhancement, a hallmark auscultatory feature, was detected. This describes the diastolic murmur's enhancement due to compression of the aneurysm track through the right ventricular wall during systole and improved flow during diastole.\u003c/p\u003e\u003cp\u003eDiagnosis of RSOV relies on multimodal imaging, including echocardiography, cardiac MSCT, and aortography. The patient\u0026rsquo;s imaging findings revealed a large RSOV aneurysm originating from the RCC, rupturing into the RA, with associated severe aortic regurgitation, ventricular dilation, and valvular dysfunction. These findings are consistent with documented RSOV cases, where aneurysm rupture into right heart chambers leads to hemodynamic instability and valvular involvement. Surgical intervention remains the definitive treatment, with repair involving aneurysm excision and defect closure using a PTFE patch. The patient underwent a standard repair via sternotomy, CPB, and PTFE patch closure. Postoperatively, TEE was normal \u0026amp; structured pharmacological management included antibiotics, beta-blockers, ACE inhibitors, and diuretics to prevent infection, stabilize hemodynamic, and manage fluid overload. These measures align with recommended postoperative care strategies to optimize recovery and prevent complications.\u003c/p\u003e"},{"header":"CONCLUSION","content":"\u003cp\u003ePhysical examination include continuous murmur is significant and must lead towards multimodal individualized diagnostic approach i.e. echocardiography, cardiac MSCT, aortography, HRCT chest, TEE and cardiac biomarker for accurate diagnosis along with personalized surgical planning and treatment regimen in RSOV. From this case 2D Echo, cardiac MSCT\u0026thinsp;+\u0026thinsp;aortography, HRCT chest played a key role to investigate RSOV and early repair with aneurysm excision and PTFE patch closure retored structural integrity and hemodynamic stability preventing further complications.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cdiv class=\"DefinitionList\"\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eACE\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eAngiotensin Converting Enzyme\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eAR\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eAortic Regurgitation\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eCPB\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eCardiopulmonary bypass\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eHRCT\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eHigh-Resolution Computed Tomography\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eIVC\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eInferior Vena Cava\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eLA\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eLeft Atrium\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eLV\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eLeft Ventricle\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eLVH\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eLeft Ventricular Hypertrophy\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eMRI\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eMagnetic resonance imaging\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eMSCT\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eMulti-Slice Computed Tomography\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003ePTFE\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003ePolytetrafluoroethylene\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003ePAH\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003ePulmonary Arterial Hypertension\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eRA\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eRight Atrium\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eRCC\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eRight Coronary Cusp\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eRV\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eRight Ventricle\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eRSOV\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eRupture of sinus of Valsalva aneurysm\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eSOV\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eSinus of Valsalva\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eSVC\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eSuperior Vena Cava\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eTEE\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eTransoesophageal Echocardiogram\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eTR\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eTricuspid Regurgitation\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eNTProBNP\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eN-terminal-pro-hormone B-type natriuretic peptide\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eNYHA\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eNew York Heart Association\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eVSD\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eVentricular Septal Defect\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003c/div\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate:\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWritten informed consent was obtained from the patient\u0026rsquo;s relatives for the publication of this case report and accompanying images.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData availability:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNo datasets were generated or analysed during the current study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interest:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no competing interest.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThere is no source of funding.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor\u0026rsquo;s contribution:\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eHJ-corresponding author and manuscript writing, MRD-acquisition and interpretation of data, manuscript writing, PBS- Conception of the work, acquisition of data, manuscript editing, HK- design of work, acquisition of data, manuscript editing, ER- Analysis of data, manuscript editing, MMR- analysis of data, manuscript editing and revising it. All the authors read and approved the final manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgement:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNone\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eSari, N. M. A. W., Dewangga, M. S. Y., Wibhuti, I. B. R., Suastika, L. O. S., Badung, I. D. G. S. M., de Liyis, B. G., Kosasih, A. M., \u0026amp; Prana Jagannatha, G. N. (2023). Ruptured sinus of Valsalva aneurysm coexisted with congenital ventricular septal defect: a case series. \u003cem\u003eThe Egyptian Heart Journal : (EHJ) : Official Bulletin of the Egyptian Society of Cardiology\u003c/em\u003e, \u003cem\u003e75\u003c/em\u003e(1), 90. https://doi.org/10.1186/s43044-023-00420-y \u003c/li\u003e\n\u003cli\u003eWeinreich, M., Yu, P.-J., \u0026amp; Trost, B. (2015). Sinus of valsalva aneurysms: review of the literature and an update on management: Sinus of valsalva aneurysm. \u003cem\u003eClinical Cardiology\u003c/em\u003e, \u003cem\u003e38\u003c/em\u003e(3), 185\u0026ndash;189. https://doi.org/10.1002/clc.22359. \u003c/li\u003e\n\u003cli\u003ePost MC, Braam RL, Groenemeijer BE, Nicastia D, Rensing BJ, Schepens MA. Rupture of right coronary sinus of Valsalva aneurysm into right ventricle. Neth Heart J [Internet]. 2010;18(4):209\u0026ndash;11. Available from: http://dx.doi.org/10.1007/bf03091763 \u003c/li\u003e\n\u003cli\u003eJohnsonfrancis.org. [cited 2024 Aug 26]. Available from: https://johnsonfrancis.org/professional/rupture-of-sinus-of-valsalva-aneurysm-rsov/ \u003c/li\u003e\n\u003cli\u003eEdwards, J. E., \u0026amp; Burchell, H. B. (1957). The pathological anatomy of deficiencies between the aortic root and the heart, including aortic sinus aneurysms. \u003cem\u003eThorax\u003c/em\u003e, \u003cem\u003e12\u003c/em\u003e(2), 125\u0026ndash;139. https://doi.org/10.1136/thx.12.2.125 \u003c/li\u003e\n\u003cli\u003eYan, F., Abudureheman, M., Huo, Q., Shabiti, A., Zhu, T., \u0026amp; Liu, Z. (2014). Surgery for sinus of Valsalva aneurysm: 33-year of a single center experience. \u003cem\u003eChinese Medical Journal\u003c/em\u003e, \u003cem\u003e127\u003c/em\u003e(23), 4066\u0026ndash;4070. https://doi.org/10.3760/cma.j.issn.0366-6999.20140715 \u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Ruptured Sinus of Valsalva Aneurysm (RSOV), Aortic Regurgitation, Heart Failure, Surgical Repair, Echocardiography, Multimodal Imaging, Cardiac surgery","lastPublishedDoi":"10.21203/rs.3.rs-7261371/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7261371/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e\u003cp\u003eRuptured Sinus of Valsalva aneurysm (RSOVA) is a rare and fatal cardiac condition characterized by an abnormal outpouching of the aortic root that ruptures into adjacent cardiac chambers typically the right atrium (RA) or right ventricle (RV). Due to its asymptomatic presentation, it often poses diagnostic and therapeutic challenges. We report this case to highlight role of early diagnosis, multimodal imaging and timely surgical intervention in improving outcomes.\u003c/p\u003e\u003ch2\u003eCase presentation:\u003c/h2\u003e\u003cp\u003eA 33-year-old hypertensive man presented with epigastric pain, abdominal discomfort, fatigue with weakness, breathlessness corresponding to New York Heart Association (NYHA) Grade II, pedal edema, palpitations, and signs of heart failure. Clinical examination revealed a bounding pulse, elevated jugular venous pressure, and a continuous murmur. 2D Echo, Cardiac MSCT\u0026thinsp;+\u0026thinsp;Aortogram, HRCT chest confirmed a RSOVA originating from the right coronary cusp (RCC) into RA, with severe aortic regurgitation (AR), severe mitral (MR) and tricuspid regurgitation (TR), and left ventricular systolic dysfunction. RSOV repair was done through sternotomy, excision of the aneurysmal sac and closure with a polytetrafluoroethylene (PTFE) patch. Postoperative management included antibiotics, cardiovascular medications, and diuretics. Follow-up echocardiography demonstrated successful repair without residual shunting, though moderate mitral regurgitation and ventricular dysfunction persisted.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e\u003cp\u003eA thorough clinical history, physical examination, timely diagnostic approach and personalized operative and treatment regimen is the cornerstone of the case. This report underscores the need for awareness of this asymptomatic rare condition and benefit of comprehensive individualized approach.\u003c/p\u003e","manuscriptTitle":"Early diagnosis and Surgical Management of a Ruptured Sinus of Valsalva Aneurysm: A Case report","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-08-27 06:15:44","doi":"10.21203/rs.3.rs-7261371/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"71682edb-8a46-4f90-b7d0-67d2baafde84","owner":[],"postedDate":"August 27th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2025-09-09T08:08:55+00:00","versionOfRecord":[],"versionCreatedAt":"2025-08-27 06:15:44","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-7261371","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7261371","identity":"rs-7261371","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}