# Ruptured Sinus of Valsalva Aneurysm With 2 Simultaneous Fistulas to the Left Ventricular Outflow Tract

## TL;DR

A rare case of a ruptured heart aneurysm with two fistulas to the left ventricle is reported, showing successful delayed surgical repair.

## Contribution

This is the first reported case of a noncoronary cusp SOVA rupturing into two left ventricular outflow tract fistulas.

## Key findings

- The patient remained asymptomatic with stable hemodynamics, allowing elective surgical repair.
- The left-to-left shunt decompressed the aneurysmal sac, preventing acute heart failure.
- Histopathological findings suggested age-related degeneration as the cause.

## Abstract

Sinus of Valsalva aneurysm (SOVA) rupture usually forms fistulas into right heart chambers; left-sided ruptures are exceedingly rare.

A 73-year-old woman presented for evaluation of ST-segment depression in V5 and V6 and moderate aortic regurgitation. Imaging revealed a noncoronary cusp–origin SOVA with 2 simultaneous fistulas into the left ventricular outflow tract. She remained asymptomatic with stable hemodynamics, allowing elective surgical repair with patch closure, direct suture, and bioprosthetic valve replacement.

The left-to-left shunt decompressed the aneurysmal sac, preventing acute heart failure. Unlike typical left-to-right ruptures, these favorable flow dynamics allowed safe delayed intervention. Histopathological examination suggested age-related degeneration rather than congenital or inflammatory etiology.

This is the first reported case of a noncoronary cusp SOVA rupturing into 2 left ventricular outflow tract fistulas. Careful hemodynamic assessment is crucial, as select patients may benefit from elective rather than urgent repair.