PM1002: A Rare Echocardiographic Finding in a Teenager Presenting with Acute Chest Pain

Introduction: Chest pain is a very common clinical presentation in the emergency department. Although most causes of chest pain in pediatrics are benign, some causes can be life-threatening. In this case, we report a case of rupture of an aneurysm of the non-coronary sinus of Valsalva (SVA) which presented as a cause of chest pain in a 16-year-old patient.

Case Description: A 16-year-old male with a past medical history of autism and developmental delay presented to the emergency room with complaints of chest pain and palpitations. His mother reported that his chest pain started suddenly 2 days ago. He was tachycardic and had a wide pulse pressure of 106/52. His Initial physical exam was remarkable for a grade V/VI loud continuous murmur over the right second intercostal space with accentuation in diastole. Inflammatory markers and cardiac enzymes were normal. Chest x-ray showed mild cardiomegaly. An echocardiogram was obtained which demonstrated reversal of flow in the thoracic aorta (Picture 1) and a windsock bulging aneurysm of the non-coronary sinus of Valsalva (SVA) which ruptured just above the tricuspid valve with significant shunting into a moderately dilated right atrium (Picture 2). The patient underwent aneurysmectomy and patch repair without evidence of an infectious process.

Discussion: Rupture of SVA is a rare cardiac anomaly in children and teenagers. Symptoms vary from sudden death to chronic congestive heart failure (CHF). SVA is seen in syphilitic aortitis, infective endocarditis, atherosclerosis, connective tissue disease or as a congenital abnormality. Timely detection of the ruptured aneurysm is of paramount importance and can be life-saving as the patient might develop cardiac ischemia from coronary insufficiency or acute CHF.

Conclusion: Chest pain can have multiple etiologies which may be cardiac or not. When chest x-ray and physical exam raise the concerns for a cardiac pathology, it is prudent to obtain a prompt diagnosis through a comprehensive echocardiogram to identify cardiac causes that can be life-threatening.