PROF. Dr. KUMAR NATARAJAN M.D.

A 32yr old patient Mr. Nagaraj was admitted with c/o breathlessness and palpitation for 20 days

HISTORY OF PRESENTING ILLNESS

H/O dyspnoea for past 20 days- class- III
H/O orthopnoea +

H/O PND +
H/O palpitation for past 20 days

-persistent

 No H/O chest pain, syncope, fatiguability No H/O fever, cough with expectoration No H/O pedal edema, facial puffiness,

decreased urine output

PAST HISTORY

NO H/O similar illness in past NOT a known case Of DM/HTN/TB/CAHD/EPILEPSY/BA

FAMILY HISTORY
Married, had two children

PERSONAL HISTORY
Not a smoker/alcoholic

GENERAL EXAMINATION
O/E

Pt conscious, oriented, afebrile, mild pallor& mild pedal edema present JVP elevated

Dancing carotids, Locomotor brachii, uvular pulsations, pistol

shot sign+ in femoral and brachial artery.

No cyanosis, clubbing, icterus, significant lymphadenopathy No thyroid swelling

VITALS
PULSE

Rate- 98/min
regular in rhythm, large volume, collapsing pulse, felt in all peripheral vessels , no radio-radial delay/radio-femoral delay

BLOOD PRESSURE Rt UL-130/40mmHg, Lt UL-130/40mmHg Rt LL- 150/40mmHg, Lt LL-150/30mmHg

RESPIRATORY RATE 24/minute

TEMP- normal

SYSTEMIC EXAMINATION
INSPECTION
Hyperdynamic apical impulse seen in Left 6TH

intercostal space, 2cm lat to MCL.

PALPATION
Parasternal heave - grade-II
Apical Impulse in left 6th ICS 2cm lateral to MCL

CONTINUOUS thrill over the left 3rd and 4th

intercostal space
Palpable p2

AUSCULTATION
LEFT 3RD AND 4TH ICS

a loud superficial continuous murmur is heard

MITRAL AREA

S1, S2 heard with the same murmur conducted

TRICUSPID AREA

S1, S2 heard with same murmur conducted

AORTIC AREA

S1, S2 heard
PULMONARY AREA

P2 loud

OTHER SYSTEMS
RS- NVBS heard, no added sounds
P/A- soft, no organomegaly CNS- NO FND

PROBLEMS
Dancing carotids, locomotor brachii, uvular

pulsations, pistol shot sign,large volume collapsing pulse signs of aortic run off
Loud superficial continuous murmur with

thrill over left 3rd and 4th ICS

D/Ds
RUPTURE OF SINUS OF VALSALVA ANEURYSM
CORONARY AV FISTULA PDA AP WINDOW ALCAPA

INVESTIGATIONS
CBC - HB -11gms

TC 7600
DC P68%, L31% PLATELET-1,50,000

URINE ROUTINE NORMAL

BLOOD SUGAR - 120mg BLOOD UREA - 30mg

SERUM CREATININE -0.8mg LIVER FUNCTION TESTS- WNL

ECG

ECG

ECG

CHEST X-RAY
IMPRESSION
CARDIOMEGALY

ECG FINDINGS
NSR,
HR- 100/min AXIS -30 LAE/LVH

ECHOCARDIOGRAPHY

ECHO FINDINGS
TTE

LV IDd 59mm LV IDs - 39mm LV EF - 62% DILATED LA/LV JERKY FLAT IVS

IMPRESSION
PROBABLE RUPTURE OF RIGHT CORONARY SINUS

 TEE
DILATED LA/LV JERKY IVS

LARGE RUPTURED ANEURYSM OF RIGHT CORONARY SINUS INTO

RVOT
RVOT GRAD- 45 OTHER CHAMBERS AND VALVES NORMAL NO E/O VEGETATIONS AND SHUNTS

IMPRESSION
RUPTURED RIGHT SINUS OF VALSALVA ANEURYSM INTO RVOT

Sinus of valsalva

FINAL DIAGNOSIS
RUPTURED RIGHT SINUS OF VALSALVA ANEURYSM INTO RIGHT VENTRICLE

TREATMENT
NASAL O2 6L/min
BED REST/BACK REST SALT & FLUID RESTRICTION T. ENALAPRIL 2.5mg 1 BD T. FRUSEMIDE 20mg 1 BD PT REFERRED TO HIGHER CENTRE FOR SURGICAL

CORRECTION

UNIQUENESS OF THIS CASE

This is the first case we have come across in our

hospital in last three years

Its a very rare disorder with incidence of 0.1-1.5% It is usually associated with other CHD such as VSD,

COA, Bicuspid Aortic valve. Any case with dyspnoea in the presence of continuous murmur may be due to ruputure of sinus of vasalva. Many of the cardiac diseases with heart failure can be treated with only medical management. But a definitive surgical cure is possible only in such cases.