An uncontainable ‘ball’ in the heart: a giant right sinus of Valsalva aneurysm

An ‘uncontainable ball’ was found swinging relentlessly within the heart of a 38-year-old previously healthy woman presenting with a three-day history of chest tightness. Auscultation identified a 3/6 blowing murmur over the aortic area. Laboratory tests revealed elevated high-sensitivity cardiac troponin I (43.4 pg/mL), NT-proBNP (4198.0 pg/mL), D-dimer (16 311 ng/mL), INR 1.7, and marked leukocytosis (WBC 20.82 × 109/L, neutrophil 84%). Hepatic and renal functions were severely impaired (ALT 1263 U/L, AST 1005 U/L, urea 10.20 mmol/L), with mildly elevated high-sensitivity C-reactive protein (7.45 mg/L). Transthoracic echocardiography unveiled the culprit—a giant (5 × 3 cm), thin-walled, ball-like aneurysm of the right sinus of Valsalva (Panels A and B; Supplementary data online, Videos S1 and S2). With every heartbeat, this ‘ball’ tumbled unrestrictedly between the right atrium and right ventricle, hammering the tricuspid valve and generating severe tricuspid regurgitation. Aortic CTA confirmed a contrast-filled saccular structure adjacent to the right coronary sinus with an ill-defined superior margin (Panels C and D), alongside multiple pulmonary emboli in the left lower lobe pulmonary artery and its branches, bilateral pleural effusions, and massive ascites. Given the critical condition, emergent surgery was performed after informed consent. Preoperative transoesophageal echocardiography re-identified the same uncontainable ‘ball’ with a 0.8 cm neck, continuous blood filling, and a 0.9 cm rupture on the right atrial side (Panels E and F; Supplementary data online, Videos S3–S5). 3D transoesophageal echocardiography clearly shows the aneurysm and the rupture site at the right atrial side (Panel G). Intraoperative findings confirmed a thin-walled aneurysm communicating between the aortic sinus and the right atrium (Panels H and I; Supplementary data online, Video S6). The procedure was completed uneventfully.