Shortness of breath and precordial discomfort are common manifestations of cardiac disease in the elderly. When those symptoms present in a young patient an acute or a congenital lesion should be suspected. This case presents a ruptured sinus of Valsalva producing a fistula between the aorta and the right ventricle that caused heart failure in a young, previously healthy man. A 19-year man developed shortness of breath and chest discomfort after weight lifting. He went for evaluation to a community hospital. Physical examination disclosed mild tachypnea, tachycardia, bibasilar crackles, wide pulse pressure, a palpable thrill and a continuous murmur heard all over the left precordium. The electrocardiogram showed sinus tachycardia. The patient underwent a transesophageal echocardiogram (TEE) that showed a fistula shunting blood from the right sinus of Valsalva into the right ventricular outflow tract. He was transferred to Puerto Rico Cardiovascular Center for surgical evaluation. At the operating room an aortotomy was performed. The ruptured aneurysmatic sinus of Valsalva with the fistula were localized and closed with hemashield patch. The intraoperative TEE detected no residual defects. The postoperative recovery was uneventful and the patient was discharged home 5 days after the surgical intervention. On postoperative follow up, he has remained free of symptoms and is willing to continue weight lifting. Aneurysm of the sinus of Valsalva is a rare congenital cardiac defect with an incidence of 0.1-1.5%. The clinical presentation of a ruptured sinus of Valsalva can range from mild heart failure to cardiogenic shock. Clinical deterioration may occur in a few days, as in this case, or it may become significant after several months. Sudden rupture of the sinus of Valsalva may occur after strenuous exertion. Although rare, this condition must be in the differential diagnosis of clinicians who evaluate young patients who present with symptoms of heart failure. A carefully performed physical examination and good clinical suspicion are essential for the detection and appropriate management of this rare entity.
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