Case Report Ruptured Sinus of Valsalva Aneurysm into the Left Atrium with Multiple Fistulous Communications: A Rare Cause of Heart Failure Yashwant Agrawal, 1 Rakshita Chandrashekhar, 1 Jerry W. Pratt, 2 Maria D. Cole, 2 Sreenivas Kamath, 2 and Jagadeesh K. Kalavakunta 2 1 Department of Internal Medicine/Pediatrics and Department of Internal Medicine, Western Michigan University Homer Stryker School of Medicine, Kalamazoo, MI 49048, USA 2 Department of Cardiology and Cardiothoracic Surgery, Borgess Medical Center, Kalamazoo, MI 49048, USA Correspondence should be addressed to Yashwant Agrawal; yashwantagrawal.agrawal@gmail.com Received 18 September 2015; Revised 12 December 2015; Accepted 16 December 2015 Academic Editor: Man-Hong Jim Copyright © 2015 Yashwant Agrawal et al. his is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Ruptured noncoronary sinus of valsalva aneurysm with istulous connections to multiple cardiac chambers has not been reported previously. We report a 66-year-old man who presented with worsening cough and exertional dyspnea. Transesophageal echocardiogram conirmed a large aneurysm involving the noncoronary cusp of the aortic sinus with aneurysmal extension to the let atrium. here were also two istulous communications with the letatrium and one small istulous connection with the right atrium. Open-heart surgery with aortic root replacement and reimplantation of coronary arteries along with primary closure and repair of aorta to the letatrial istula was performed. 1. Introduction hough ruptured sinus of valsalva aneurysm is a rare entity when it occurs, emergent surgical intervention should be the treatment of choice as patients can deteriorate rapidly and if required prophylactic repair of other structures such as impending aneurysm should be performed, as in our case, to prevent future catastrophes. 2. Case History A 66-year-old man presented to the emergency room with worsening cough, exertional dyspnea, and orthopnea for 3 weeks. Physical examination was remarkable for a grade III/VI continuous murmur at the second right upper ster- nal border. Initial lab values were remarkable for troponin 0.1 ng/mL (normal, 0–0.16 ng/mL) and brain natriuretic pep- tide 761 ng/mL (normal, 0–450 ng/L). He was placed on intravenous furosemide, which improved his symptoms. A transthoracic echocardiogram showed marked dilatation of sinuses of valsalva and an aneurysm, which seemed to have ruptured into the letatrium (LA). For better assessment, a transesophageal echocardiogram (TEE) was performed which showed large aneurysm involving the noncoronary cusp of the aortic sinus of valsalva extending into LA (Figure 1). he gradient across the communication was 65 mmHg. Two istulous connections with LA were also appreciated along with a small istulous connection with right atrium. he aortic valve was eufunctional without any steno- sis or regurgitation on TEE. Two days later, he developed acute dyspnea and went into cardiogenic shock. His vitals were signiicant for blood pressure of 80/46 mmHg, heart rate 128 bpm, and respiratory rate 30/minute with saturation of 78%. His lab values were remarkable for creatinine increasing to 2.8 mg/dL from 1.3 mg/dL (normal, 0.6–1.2 mg/dL) and brain natriuretic peptide 1500 ng/mL from 764 ng/mL. He underwent emergent sinus of valsalva aneurysm (SVA) repair and aortic root replacement with 25 mm freestyle aortic root. During the procedure, a large SVA of the noncoronary sinus was noted, herniating into the LA. At the end of the windsock, Hindawi Publishing Corporation Case Reports in Cardiology Volume 2015, Article ID 627946, 3 pages http://dx.doi.org/10.1155/2015/627946