Sinus of Valsalva Aneurysm from Left Coronary Sinus with Aortic Root Dilatation: A Rare Case

Sinus of Valsalva aneurysm is an uncommon cardiovascular anomaly, most often arising from the right coronary sinus. In contrast, aneurysms originating from the left coronary sinus are extremely rare and pose unique diagnostic as well as surgical challenges because of their close relationship to the left main coronary artery, left atrium, and pulmonary artery. We encountered a 57-year-old woman who presented with acute dyspnea and a history of syncope. Initial transthoracic echocardiography followed by contrast-enhanced computed tomography revealed a large aneurysm arising from the left coronary sinus with a characteristic “windsock”-shaped fistulous tract directed toward the left atrium, along with associated aortic root dilatation. Transesophageal echocardiography confirmed the origin of the aneurysm and its communication into a 4.5 × 4.5 cm cystic cavity located adjacent to the left atrium. Because of the close anatomic relationship between the aneurysm and the left main coronary artery, the operative plan was modified. The surgical team proceeded with aneurysm resection and pericardial patch repair, and in view of potential compromise of the left main coronary artery, prophylactic coronary artery bypass grafting was carried out using reverse saphenous vein grafts to the left anterior descending and obtuse marginal arteries. Intraoperative and postoperative transesophageal echocardiography confirmed successful exclusion of the fistula, intact repair, and patent grafts. This case illustrates the rare occurrence of a left coronary sinus of Valsalva aneurysm communicating with the left atrium, emphasizes the diagnostic and perioperative value of transesophageal echocardiography, and highlights the importance of individualized surgical strategies. Prophylactic bypass grafting was a critical step in preventing left main coronary artery compromise and contributed to a successful outcome.