Approach Considerations
In the 2018 American Heart Association/American College of Cardiology (AHA/ACC) guideline for the management of adults with congenital heart disease, sinus of Valsalva aneurysm (SVA) is classified as a lesion with moderate anatomic complexity. No specific recommendations are provided to guide evaluation or treatment. [20]
Similarly, the 2020 European Society of Cardiology (ESC) guidelines for the management of adult congenital heart disease also categorize SVA as being of moderate anatomic complexity, and no specific diagnostic or management recommendations are laid out. [12, 13]
Medical Care
Medical management of sinus of Valsalva aneurysm (SVA) usually involves clinical stabilization (eg, optimizing medications for heart failure syndrome) and perioperative assessment and management. [14]
Transcatheter closure of ruptured SVA has been successfully performed using Amplatzer devices. [21, 22, 23] Ruptured SVAs have been treated with transcatheter closure to avoid sternotomy and cardiopulmonary bypass in critically ill patients.
Although advanced percutaneous techniques have been performed in the correction of this anomaly, open-heart surgery with or without aortic valve replacement remains the standard of care. A surgical approach may also allow additional procedures such as aortic root replacement or ventricular septal defect closure. [10, 12, 13]
Surgical Care
Cardiothoracic surgery consultation is urgent in patients with ruptured sinus of Valsalva aneurysm (SVA), because clinical deterioration can be rapid.
Conventionally, with an operative mortality below 2%, surgical repair of the ruptured SVA has been the mainstay of therapy. Urgent surgical repair is recommended in all patients with ruptured SVA, especially with intracardiac shunting. [24, 25, 26] Aggressive surgical correction of unruptured SVA is often recommended because of the lesion's association with increased morbidity and mortality. [8, 27, 9, 28, 29, 30]
Surgical repair may include the following procedures:
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Aortic root reconstruction or replacement
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Aortic valve repair or replacement
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Bentall procedure (valved conduit)
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Ventricular septal defect repair (if present)
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Atrial septal defect repair (if present)
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Primary suture closures (pledget) and patch closures (if ruptured)
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Sinus of Valsalva Aneurysm. An axial slice from an electrocardiography (ECG)-gated computed tomographic angiogram (CTA) demonstrates an aneurysm of the right sinus of Valsalva (arrow). There is a filling defect within the aneurysm consistent with a thrombus.
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Sinus of Valsalva Aneurysm. A parasagittal slice from an electrocardiography (ECG)-gated computed tomographic angiogram (CTA) demonstrates a right sinus of Valsalva aneurysm (arrow). There is a filling defect within the aneurysm consistent with a thrombus.
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Sinus of Valsalva Aneurysm. A three-dimensional reconstruction of a computed tomographic (CT) aortogram is shown, demonstrating a right sinus of Valsalva aneurysm (arrow).
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Sinus of Valsalva Aneurysm. A mid-esophageal short-axis echocardiogram demonstrates a ruptured right sinus of Valsalva aneurysm. Color doppler demonstrates flow into the right ventricle.
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Sinus of Valsalva Aneurysm. A mid-esophageal long-axis echocardiogram demonstrates a ruptured right sinus of Valsalva aneurysm. Color doppler demonstrates flow into the right ventricle.
