Cardiovascular Journal of Africa: Vol 28 No 4 (July/August 2017)

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CARDIOVASCULAR JOURNAL OF AFRICA • Volume 28, No 4, July/August 2017 AFRICA e1
An unusual case of aorta–right atrial tunnel with
windsock aneurysm: imaging, diagnosis and treatment
Shehzaadi Aneesah Mohamed Khan, Leonie Scholtz, F Adriaan Snyders, Johan de Villiers
Abstract
The first successfully diagnosed and treated case of aorta–
right atrial tunnel was reported by Coto et al. in 1980. The
most common cause of aorta–right atrial tunnel is a ruptured
aneurysm of the sinus of Valsalva. Sinus of Valsalva aneu-
rysms had been reported as early as 1840 by Thurnam; these
were diagnosed at autopsy. With the advances in radiology,
many cases of aorta–right atrial tunnel have been reported
since then, each with its own subtle variations.
We report on a unique case of aorta–right atrial tunnel
with a windsock aneurysm in the right atrium. A 55-year-
old male presented with abdominal pain and the chest X-ray
revealed cardiomegaly. On further investigation with echo-
cardiography and computed tomography angiography, there
was an incidental aorta–right atrial tunnel with a windsock
aneurysm in the right atrium. He was treated successfully
with surgery. A similar case has been reported only once
before by Iyisoy et al. in 2014.
Keywords: aorta–right atrial tunnel, aneurysms of the sinus of
Valsalva
Submitted 27/10/15, accepted 10/7/16
Published online 15/3/17
Cardiovasc J Afr 2017; 28: e1–e5
DOI: 10.5830/CVJA-2016-073
As earlyas 1840, aneurysms of the sinus of Valsalvaweredescribed
by Thurnam; these were diagnosed through autopsies.1 The first
successfully diagnosed and treated case of aorta–right atrial
tunnel was reported by Coto et al. in 1980.2 Initially, diagnosis
was limited to echocardiography and cardiac catheterisation,
but with the advent of 64-slice computed tomography (CT)
angiography, diagnostic accuracy and accessibility has improved.
We present here a unique case of aorta–right atrial tunnel
with a windsock aneurysm in the right atrium, diagnosed with
echocardiography and CT angiography and successfully treated
with surgery.
Case report
A 55-year-old male patient presented with abdominal pain and
was admitted to hospital for the treatment of a kidney stone.
Two days after the stone was removed and a stent was placed,
he complained again of severe abdominal pain, nausea and
vomiting. He was thoroughly examined; the abdominal CT and
ultrasound were normal. The cause of abdominal pain was due
to a urinary tract infection, which he had contracted after the
urinary tract stone was removed. The abdominal symptoms
were unrelated to the cardiac findings. The chest radiograph,
however, demonstrated cardiomegaly. He was then referred to a
cardiologist.
The patient had no history of cardiac disease and reported
no chest pain or palpitations. He had normal effort tolerance. In
retrospect he recalled some ankle swelling during the afternoons
and mild peri-orbital swelling during the mornings. His surgical
history included a Nissen fundoplication.
A transthoracic echocardiogram demonstrated a large left
atrium and left ventricle. No left ventricular hypertrophy was
reported. Ejection fraction onM-mode was normal. A significant
finding was an impression on the enlarged right atrium from a
possible adjacent lesion.
The transoesophageal echocardiogram (TEE) confirmed
normal valvular and left ventricular function. There was an
aneurysm of the aortic sinus with a windsock in the right atrium,
possibly increasing the pressure and volume in the right atrium
(Figs 1–3).
A CT angiogram was performed subsequent to the TEE.
There was aneurysmal dilatation of the right coronary sinus
with a tortuous dilated tunnel draining anteriorly into the right
atrium. The distal end of the tunnel appeared to have a large sac/
windsock aneurysm, which protruded into the right atrium. The
sac was not intact along its lateral border, forming a left-to-right
shunt from the coronary sinus to the right atrium. There were
extensive calcifications noted along the wall of the tunnel. The
right coronary artery arose from the proximal part of the tunnel
(Figs 4, 5).
The patient was referred to the cardiothoracic surgeon for
surgical repair of the aorta–right atrial tunnel, which was an
incidental finding. The defect in the aorta was in the right
coronary sinus and the lower border was approximately 4
mm from the aortic annulus (Fig. 6). The aneurysm formed a
windsock with more than one opening, all of which were in the
right atrium.
The right atrium was opened and a retrograde cardioplegic
cannula was placed in the coronary sinus. Retrograde cardioplegia
was used due to the presence of the left-to-right shunt created by
University of Pretoria, Pretoria, South Africa
Shehzaadi Aneesah Mohamed Khan, MB ChB,
Leonie Scholtz, MB ChB, MMed (RadD)
F Adriaan Snyders, MB ChB, MMed (Int), FACC, FESC
Johan de Villiers, MB ChB, MMed (thorax), GKC (thorax)
Case Report