DOI: 10.1111/j.1540-8175.2009.01147.x C  2010, Wiley Periodicals, Inc. CASE REPORTS Surgery for Ruptured Sinus of Valsalva Aneurysm into Right Ventricular Outflow Tract: Role of Intraoperative 2D and Real Time 3D Transesophageal Echocardiography Shrinivas Gadhinglajkar, M.D., and Rupa Sreedhar, M.D. Department of Anesthesia, Sree Chitra Tirunal Institute For Medical Sciences and Technology, Trivandrum, Kerala, India A major limitation of the 2D echocardiography during surgery for a complex cardiac lesion is its inability to provide an accurate spatial orientation of the structure. The real time 3D transesophageal echocar- diography (RT-3D-TEE) technology available in Philips IE 33 ultrasound machine is relatively new to an operation suite. We evaluated its intraoperative utility in a patient, who was operated for repair of a ruptured sinus of Valsalva aneurysm (RSOVA) and closure of a supracristal ventricular septal defect. The VSD and RSOVA were visualized through different virtual windows in a more promising way on intraop- erative RT-3D-TEE than on the 2D echocardiography. The acquired images could be virtually cropped and displayed in anatomical views to the operating surgeon for a clear orientation to the anatomy of the lesion. RT-3D-TEE is a potential intraoperative monitoring tool in surgeries for complex cardiac lesions. (Echocardiography 2010;27:E65-E69) Key words: three-dimensional transesophageal echocardiography, intraoperative transesophageal echocardiography, sinus of Valsalva A major limitation of the 2D echocardiography during surgery for a complex cardiac lesion is its inability to provide an accurate spatial orientation of the structure. Real time 3D transesophageal echocardiography (RT-3D-TEE) technology is rel- atively new to an operation suite. We evaluated its intraoperative utility in a patient, who was op- erated for repair of a ruptured sinus of Valsalva aneurysm (RSOVA) and closure of a supracristal ventricular septal defect (SCVSD). Case Report: A 23-year-old male patient, weighing 62 kg, was operated for repair of a right RSOVA and closure of a SCVSD. The patient was diagnosed to have the SCVSD with prolapse of right coronary cusp (RCC) 5 years ago and was advised to undergo surgical repair. Patient was unwilling for surgical treatment at that time and was subsequently lost to follow-up until 7 days before surgery, when he presented to us with 1-month symptoms of acute exacerbation in dyspnea on exertion (grade III). Address for correspondence and reprint requests: Dr Shrini- vas Gadhinglajkar, M.D., Additional Professor, Department of Anesthesia, Sree Chitra Tirunal Institute For Medical Sciences and Technology, Trivandrum, Kerala, Pin Code: 695011, India. Fax: (91) 0471-2446433; E-mail: shri@sctimst.ac.in His cardiovascular examination revealed blood pressure of 180/40 mmHg and a 5/6 continuous murmur in left upper parasternal area. Preoper- ative transthoracic echocardiography showed a SCVSD with right SOVA that had ruptured into right ventricular outflow tract (RVOT). Observa- tions on catheter studies in addition to the RSOVA were pulmonary to systemic cardiac output ratio of 1.8:1; pulmonary artery (PA) oxygen satura- tion of 84%; PA systolic pressure of 83 mmHg; and normal coronary arteries. After anesthesia induction, heart was in- spected using RT-3D-TEE with an ultrasound ma- chine (IE 33, Philips Medical Systems, Bothell, WA, USA). Initial 2D examination showed a right RSOVA prolpasing into RVOT and significantly blunting the systolic flow across the SCVSD. The trileaflet aortic valve (AV) appeared mildly in- competent due to the coaptation defects present among the leaflets (Fig. 1, movie clip 1). A peak systolic gradient of 31 mmHg was present be- tween the aorta and RVOT at a systemic systolic pressure of 112 mmHg. Systolic flow acceleration with a peak systolic gradient of 30 mmHg was detected across the RVOT on transgastric naviga- tion. Other observations were the AV annulus of 27 mm in diameter; and absence of vegetations on the AV or in the SOVA. E65