CASE REPORT
A 31-year-old women with unremarkable medical history was consulted at
the ambulatory complaining of dyspnea and edema of the lower limbs
lasting about 2 months. The patient had no history of endocarditis,
trauma, previous surgery or other heart disease diagnosed so far. On
physical evaluation, cardiac auscultation showed a rude, high-frequency
holosystolic heart murmur, pancardiac, 4+/6+ according to Levine’s
scale, and bilateral lower limbs edema. Transthoracic echocardiography
was performed, which showed (I) moderate atrial dilatation, (II)
secondary pulmonary hyperflow and (III) high-pressure blood flow
directed from the right Valsalva sinus to the right ventricle, with
intense retrograde flow over pulmonary valve, resulting in its
functional insufficiency.
Decided for her admission to clinical compensation and diagnostic
complementation. After clinical improvement, cardiac catheterization of
the left and right chambers was performed, which revealed (I) coronary
arteries free of atherosclerotic disease, (II) hyperflow from the aorta
to right ventricular cavity, (III) right ventricular diastolic overload,
(IV) moderate functional tricuspid valve incompetence and (IV)
appearance of pulmonary hyperflow. Hence, it was decided for surgical
approach to correct the defect.
Surgical access was performed by median longitudinal sternotomy,
installation of extracorporeal circulation circuit with aortic cannula
positioned in ascending aorta and bicaval venous drainage. Hypotermia up
to 32ºC, transverse aortotomy, identification of the orifice in the
right Valsalva sinus of the right coronary leaflet, with communication
to the right ventricle outflow tract.
The fistula tissue was resected and the orifice was closed with bovine
pericardium and prolene 5.0 thread.
The surgery had no complications during operation, and the patient was
discharged at the fifth day after the procedure. In the postsurgical
outpatient evaluation, the patient was asymptomatic, and the
echocardiography did not show communication between the right sinus of
valvalsa to the right ventricle anymore.