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PROF. Dr. KUMAR NATARAJAN M.D.,

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A 32yr old patient

Mr. Nagaraj was

admitted with

c/o breathlessness

and palpitation for20 days

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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

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No H/O chest pain, syncope, fatiguability

No H/O fever, cough with expectoration

No H/O pedal edema, facial puffiness,

decreased urine output

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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

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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

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VITALS PULSE

Rate- 98/min

regular in rhythm,

large volume,

collapsing pulse, felt in all peripheral vessels ,

no radio-radial delay/radio-femoral delay

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BLOOD PRESSURE

Rt UL-130/40mmHg,

Lt UL-130/40mmHg

Rt LL- 150/40mmHg,

Lt LL-150/30mmHg

RESPIRATORY RATE 24/minute

TEMP- normal

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SYSTEMIC EXAMINATION

INSPECTION

Hyperdynamic apical impulse seen in Left 6TH

intercostal space, 2cm lat to MCL.

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PALPATION Parasternal heave - grade-II

Apical Impulse in left 6th

ICS 2cm lateral to MCL CONTINUOUS thrill over the left 3rdand 4th

intercostal space

Palpable p2

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AUSCULTATION LEFT 3RDAND 4THICS

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

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OTHER SYSTEMS

RS- NVBS heard, no added sounds

P/A- soft, no organomegaly

CNS- NO FND

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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 3rdand 4thICS

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D/Ds RUPTURE OF SINUS OF VALSALVA ANEURYSM

CORONARY AV FISTULA

PDA

AP WINDOW

ALCAPA

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INVESTIGATIONSCBC - 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

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ECG

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ECG

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ECG

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CHEST X-RAY

IMPRESSION

CARDIOMEGALY

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ECG FINDINGS NSR,

HR- 100/min

AXIS -30

LAE/LVH

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ECHOCARDIOGRAPHY

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ECHO FINDINGSTTE LV IDd 59mm

LV IDs - 39mm

LV EF - 62% DILATED LA/LV

JERKY FLAT IVS

IMPRESSIONPROBABLE RUPTURE OF RIGHT CORONARYSINUS

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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

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Sinus of valsalva

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FINAL DIAGNOSIS

RUPTURED RIGHT SINUS OF VALSALVAANEURYSM INTO RIGHT VENTRICLE

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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

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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 adefinitive surgical cure is possible only in such cases.

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