Right Ventricular Intramyocardial Dissecting Hematoma Caused by Contained Rupture of an Infective Pseudoaneurysm of the Right Coronary Sinus of Valsalva: A Case Report

Periannular extension of native aortic valve infective endocarditis may lead to abscess formation, pseudoaneurysms, and fistulous communications with adjacent cardiac structures.We report an unusual complication involving a right ventricular intramyocardial dissecting hematoma caused by contained rupture of an infective pseudoaneurysm of the right sinus of Valsalva.A 29-year-old woman presented with severe chest pain radiating to the back, rapidly progressive dyspnea, and hemodynamic shock following one month of intermittent fever.Computed tomography angiography revealed massive hemopericardium and a suspected ruptured pseudoaneurysm of the right sinus of Valsalva.Emergency surgery initially revealed active bleeding from a right ventricular intramyocardial dissecting hematoma following evacuation of the massive hemopericardium.A subsequent aortic exploration showed destructive infective endocarditis of the native aortic valve, complicated by a pseudoaneurysm of the right sinus of Valsalva that had ruptured in a contained way into the free wall of the right ventricle.Radical debridement, a modified Bentall replacement, and coronary revascularization using a Y-shaped saphenous vein graft were performed.Despite emergency surgery, the patient died from refractory postoperative vasoplegic shock.This case demonstrates an unusual pathway of rupture of a right sinus of Valsalva pseudoaneurysm in destructive native aortic valve infective endocarditis, in which intramyocardial dissection of the right ventricular free wall preceded hemopericardium and cardiac tamponade.