A 47 year old female healthy, asymptomatic farmer underwent routine medical screening in rural China. A early diastolic murmur was detected. Subsequent color doppler echocardiogram showed a competent aortic valve but a fistulous communication of a perforated Valsalva aneurysm into the left ventricle. Computed tomography revealed a multi cavernous cauliflower-shaped Valsalva aneurysm involving the whole aortic basisor bulbous aortae and all sinuses.
A sinus of Valsalva aneurysm (SVA) was first described by Thurman in 1840 . A rare abnormality of the heart, a sinus of Valsalva aneurysm, may be caused by a separation or localized connective tissue dystrophy of the aortic tunica media and the annulus fibrosus of the aortic valve . Such a SVA may be congenital or acquired  with an incidence as low as <1.5% among congenital heart disease repairs . It is the least common of all aortic aneurysms. If not congenital but acquired causes include atherosclerosis, cystic media necrosis, infective or post-traumatic injuries . Sinus of Valsalva aneurysmmore prevalent originates from the right coronary sinus (70-90%), have been seen less commonly from the non-coronary sinus (10-20%), and rarely from the left sinus (<5%) . The incidences of SVA are reported to be higher in Asian than Western populations, and the male: female ratio was found to be 4:1 . Un-ruptured sinus of Valsalva aneurysms normally do not cause any symptoms unless they rupture, causing fistulous communications, heart failure and death [3,4,8,9].
A 47 year old female patient was admitted because of an early diastolic murmur which was detected during a routine medical screening of the rural population in north-east China in Jilin Province, close to the North Korean border. The female patient, working as a farmer and doing heavy work in the fields, was completely asymptomatic and had no shortness of breath and
no dyspnea during her work. On admission she was in New York
Heart Association class I, regular sinus rhythm and normal blood pressure, no diabetes, normal body mass index, no prevalence of metabolic syndrome, but a heavy smoker. The early diastolic murmur was confirmed but color doppler echocardiogram showed a somewhat ‘difficult’ result. Investigated by different cardiologists we received different interpretations. The first reported signs of a congenital heart disease and a moderate ‘aortic’ incompetence but a competent aortic bicuspid valve, however some signs of aortic valve (AV) perforation.
The AV opening area was calculated 1.9cm2, the AV max peak gradient (PG) 56mmHg, Ejection Fracture (Simpson) 74%, the ascending aorta with a post-stenotic dilatation with a diameter of ø4.2cm, LVIDd 4.2cm and AV V max 376 cm/sec. The other reported a combined aortic valve lesion with stenosis and incompeence, some AV vegetations, Vmax 471cm/sec and AV max PG 89mmHg. Repeated color doppler echocardiograms showed a moderate flow through a perforated SVA into the outflow tract of the left ventricle and thickened and deformed obviously bi-leaflet aortic valve leaflets (Figure 1). Computed tomography confirmed cavernous sinus of Valsalva aneurysmatic structures right below the level of the sinutubular junction and fistulous communications of a perforated SVA (Figure 2).Three-dimensional computed tomography confirmed a dilated ascending aorta and multiple cavernous, cauliflower-like Sinus of Valsalva structures surrounding the deformed base of the aorta (Figure 3).
There was a clear indication for surgery due to a significant
aortic stenosis and a perforated SVA. However, the patient, a
farmer from the countryside in rural China, refused surgery
because the family could not afford the surgical treatment. There
are significant socio-economic disparities in China and a massive
gap between urban and rural population groups . While the
wealthier share of the Chinese population has benefited from
advanced health technologies and spending on health care, the
poor have lost access to even the most essential services. In terms of rural-urban disparity across provinces, life expectancy
drops parallel to a rising share of rural population .