Imaging Studies
Transthoracic echocardiography (TTE) and transesophageal echocardiography (TEE) have traditionally been used to diagnose sinus of Valsalva aneurysm (SVA), but electrocardiography (ECG)-gated computed tomographic angiography (CTA) and cardiac magnetic resoance imaging (CMRI) have gained popularity in recent decades. [2, 17]
Multiplane TEE provides conclusive information regarding SVA and allows precise identification of structural anomalies and shunt locations for perioperative assessment. [3, 14]
Two-dimensional TTE may detect as many as 75% of all patients with SVA. [18, 19] Color-flow Doppler imaging is considered the technique of choice for identifying a ruptured SVA. However, the use of contrast echocardiography is helpful in delineating the aneurysm and shunt arising from rupture. The presence of a left-to-right shunt can be confirmed by demonstrating a negative contrast image in the right-sided cavities. Usually TEE, EGG-gated CTA, or CMRI is needed to confirm the diagnosis and for perioperative assessment.
Features of SVA on TTE include the following:
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Generalized single sinus enlargement
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"Wind-sock" extension of the sinus from the body and/or apex of an otherwise normal aortic sinus when ruptured
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Detection of associated defects, including ventricular septal defect, bicuspid aortic valve, and aortic insufficiency
ECG-gated CTA and CMRI may provide valuable three-dimensional data for procedural planning.
Electrocardiography usually reveals sinus tachycardia, although conduction defects may occur.
Procedures
Although rarely necessary, the definitive diagnosis of sinus of Valsalva aneurysm can be confirmed by performing a retrograde thoracic aortography or cardiac catheterization. Left-to-right shunting also can be demonstrated if the SVA is 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.
