Rupture of right sinus of Valsalva aneurysm with alternating shunting into right atrium and right ventricle

Sinus of Valsalva aneurysm (SVA) is a rare cardiac anomaly that may be congenital or acquired. We report the case of a 29-year-old female who presented with a three-month history of exertional dyspnea. Cardiac auscultation revealed a grade III/VI continuous murmur along the right sternal border. Transthoracic echocardiography revealed alternating jet-flows into the right atrium (RA) and right ventricle (RV) during different phases of the cardiac cycle. The aortography revealed periodic movement of a jet of contrast medium, which was due to a long windsock SVA swimming between RA and RV. The aneurysm descended into the tricuspid orifice during diastole, and was possibly lifted by the leaflet of the tricuspid valve closure during systole. The patient underwent open-heart surgery to close the aneurysm ostium and directly suture the right atrial fistula.