Ruptured sinus of valsalva into right ventricle: a unique case with prolonged survival.

A 51 years male motor mechanic turned shopkeeper presented to us with complaints of progressive exertional breathlessness and pitting pedal edema for last one year. On examination, a wide pulse pressure (160/40 → 0) was found and a continuous murmur (with thrill) was heard over his left parasternal region, best in the 3rd and 4th intercostals spaces, that was more prominent during diastole. A clinical diagnosis of ruptured sinus of Valsalva into right ventricular was made. Upon reviewing his records it was found that he was first diagnosed as having this illness in 1979 when he presented as a 26 year old man with sudden onset chest pain with severe breathlessness. Although advised surgery then, he did not comply. Eleven years later (in 1991) he again came to this institute and was referred to cardiology as a case of Pyrexia of Unknown Origin (PUO). Echocardiography and blood cultures done then established the diagnosis of infective endocarditis. With appropriate antibiotics he improved and was cured of infective endocarditis. Even after this episode of infective endocarditis he refused surgery. By judicious curtailment of his activities involving strain, and with medical therapy he had so far led a productive life. This time he presented with the dyspnea on exertion (NYHA class II) and over these years began to perceive his murmur (complains he hears it). We performed his ECHO (Figs. 1, 2, 3) and wish to report this case since a limited number of patients have been reported with as long productive lives after rupture of sinus of valsalva into right ventricle. Whereas, in most cases this illness is known to proceed quickly to decompensated failure, there are a very few reports of prolonged survival. Chojnacki1 reported a case who underwent surgery after 15 years of detection. Another patient survived 17 years.2 An interesting case report of aneurysm of all three sinus of valsalva was published in 19403, and the subject survived 30 years. Our patient has survived 25 years now since rupture and is amongst the longest reported survivors.