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.