Ruptured infective sinus of valsalva aneurysm complicated by peripheral mycotic pulmonary artery aneurysm: a case report

BACKGROUND: Ruptured sinus of Valsalva aneurysm associated with infective endocarditis is a rare but life-threatening condition. Peripheral mycotic pulmonary artery aneurysm is even rarer and carries a high risk of rupture. The coexistence of infective ruptured sinus of Valsalva aneurysm and a peripheral mycotic pulmonary artery aneurysm has not been previously reported. CASE PRESENTATION: A 58-year-old woman developed pneumonia and infective endocarditis with mobile vegetation in the right ventricular outflow tract, resulting in right ventricular outflow tract stenosis and septic pulmonary embolism. During antibiotic therapy, computed tomography incidentally revealed a peripheral mycotic pulmonary artery aneurysm. Because of the high risk of rupture, urgent transcatheter coil embolization was performed. Both transthoracic echocardiography and cardiac CT suggested a communication; however, neither modality allowed definitive differentiation between ventricular septal defect and ruptured sinus of Valsalva aneurysm due to severe right ventricular outflow tract obstruction. Subsequent transesophageal echocardiography clearly demonstrated a ruptured sinus of Valsalva aneurysm originating from the right coronary sinus and draining into the right ventricle, and definitive surgical repair was successfully performed. The postoperative course was uneventful, with no recurrence of infection or aneurysm enlargement during a two-year follow-up period. CONCLUSIONS: This case highlights the importance of early recognition and multidisciplinary decision-making in patients with infective endocarditis complicated by rare vascular lesions. Prioritizing endovascular treatment of a peripheral mycotic pulmonary artery aneurysm before open heart surgery may reduce the risk of catastrophic pulmonary hemorrhage during cardiopulmonary bypass.