Surgical management for unruptured sinus of Valsalva aneurysms: a narrative review of the literature

Missed transthoracic echocardiography diagnosis of unruptured sinus of Valsalva aneurysm with thrombus: a case report

Background

Unruptured sinus of Valsalva aneurysm (SVA) is a rare congenital or acquired cardiac lesion. It may remain asymptomatic or present with various clinical manifestations due to its 'mass effect' on the coronary arteries, valves, atria, and other adjacent structures. Unruptured SVA also carries the risk of secondary complications such as infection, thrombosis, and rupture, posing a serious threat to patient health.

Case summary

A 55-year-old male from the central region of China, who presented with chest tightness following COVID-19 infection, underwent transthoracic echocardiography (TTE) one year before, which revealed an unruptured non-coronary SVA. Recent follow-up TTE showed findings consistent with the previous examination. Coronary computed tomography angiography (CCTA) subsequently demonstrated a non-coronary SVA complicated by a large thrombus and atherosclerotic changes in the aortic sinus wall. Due to the significant risk of thrombus dislodgement and subsequent systemic embolism, the patient underwent surgical thrombectomy and plasty of the non-coronary SVA. Intraoperative transoesophageal echocardiography (TEE) and surgical exploration confirmed the presence of a mural thrombus; while the potential association between COVID-19 infection and aneurysm formation remains to be fully elucidated. At the 6-month postoperative follow-up, the patient demonstrated favourable physical recovery, with no reported thrombo-embolic events (e.g. stroke or systemic embolism), recurrent symptoms, or other adverse clinical outcomes. A repeat TTE during follow-up revealed a well-preserved aortic root morphology, with normal dimensions and no signs of residual aneurysm or valvular dysfunction.

Discussion

We report a unique instance of a massive thrombosed non-coronary SVA. Considering the limitations of TTE and its low sensitivity to SVA secondary lesions, it is recommended to further perform TEE or CCTA to comprehensively evaluate the morphology and structure of SVA.

A rare case rupture of sinus of Valsalva aneurysm in a peripheral hospital

Background: The sinus of Valsalva aneurysm (SVA) is an uncommon cardiac abnormality that may be either congenital or acquired. Case: In this case we describe a 73-year-old man who complained of acute shortness of breath. Echocardiography showed rupturing of a sinus Valsalva aneurysm into the right ventricle with ventricular septal defect/rupture diagnoses in a peripheral hospital far from a reference hospital. Conclusion: Echocardiography can aid in distinguishing between different diagnoses and serve as a catalyst for more exploration into the underlying cause. This can enhance the likelihood of early detection of an SVA and enable the implementation of an effective management strategy.

Sudden Death Due to Rupture of Aneurysm of Sinus Valsalva: An Autopsy Case

ABSTRACT

Aneurysm of sinus Valsalva is a defined as dilatation of the sinuses located between the aortic valve annulus and the sinotubular junction and mostly found in the right coronary sinus. It can be either congenital or acquired. This condition is usually asymptomatic unless it can cause intracardiac rupture or aortic valve insufficiency. Extracardiac rupture and associated fatal cases of cardiac tamponade are extremely rare. Our case is one of the rare cases in the literature that was diagnosed during autopsy. Our case is 65-year-old male patient with a history of hypertension suddenly fell ill after swimming in the sea. On gross examination of heart, there was an aneurysmatic enlargement of the right sinus Valsalva measuring 4.5 × 4 cm with a hemorrhagic appearance on the outer surface and a 0.3 cm rupture area. Histopathological examination revealed hemorrhage in and around the aneurysm wall.

Giant unruptured sinus of Valsalva aneurysms causing angina pectoris

BACKGROUND

Sinus of Valsalva aneurysm (SVA) is a rare cardiac anomaly which can be congenital or acquired. Patients with SVA are commonly asymptomatic when the occupying effect of SVA is insignificant, while ruptured SVA usually causes severe symptoms including heart failure and myocardial ischemia.

CASE PRESENTATION

We present an unusual case of a 64-year-old female manifesting with exertional dyspnea as well as angina pectoris for three months. Echocardiography and cardiac computed tomographic angiography confirmed unruptured left-coronary and non-coronary SVAs. The left anterior descending artery and left circumflex artery were stretched and compressed by the SVA which causing myocardial ischemia. The patient finally received aortic root replacement (Bentall procedure) and got symptom relieved.

CONCLUSIONS

Giant unruptured SVA originating from left coronary sinus is extremely rare. Our case highlights that giant SVA should be considered in cases with angina pectoris. Echocardiography and coronary computed tomographic angiography are useful and important for diagnosis. Surgery is highly recommended in patients with SVA.

Ruptured Sinus of Valsalva Aneurysm: Three Case Reports and Literature Review

Sinus of Valsalva aneurysm rupture (SOVAR) into the right cardiac chambers is an uncommon complication with unusual presentation, high morbidity and mortality, and unique hemodynamics as well as cardiac imaging findings. Here, we present three SOVAR cases (two with rupture into the right atrium and one with rupture into the right ventricle) that were initially confused for ventricular septal defects and describe their initial presentation, cardiac imaging studies, invasive hemodynamics, as well as treatment options. Some of the unique findings of SOVAR patients include an acute presentation, often with hemodynamic decompensation, the presence of a continuous murmur on examination, and also hemodynamics that include wide pulse pressure and right heart volume overload.

Virtual Imaging of Unruptured Sinus of Valsalva Aneurysm and Autologous Pericardial Patch

An asymptomatic 78-year-old man with no major medical history was diagnosed with an unruptured sinus of Valsalva aneurysm. The complexity of the anatomic relationships around the aneurysm when observed only by preoperative contrast-enhanced computed tomography and transthoracic echocardiography made it difficult to choose a treatment strategy. Accordingly, virtual imaging was reconstructed from the computed tomography data. Autologous pericardial patch closure with sparing of the aortic valve and annulus was successfully performed on the basis of virtual imaging.

Severe Aortic Regurgitation From Sinus of Valsalva Aneurysm Prolapse

•Unruptured SVAs are usually asymptomatic but can present with significant HF. •A large SVA can compress or displace nearby structures and cause valvular abnormalities. •Echocardiography plays an important role in diagnosis and management of SVA.

Sinus of Valsalva Pseudoaneurysm: An Unusual Cause of Complete Heart Block

We present a case of a young man with complete atrioventricular block and aneurysm of the right sinus of Valsalva penetrating the interventricular septum and causing severe aortic regurgitation. Chest trauma and inflammatory or infectious diseases are potential causes. Bentall-de Bono surgical repair was performed. Anatomopathologic analysis demonstrated fibrosis, hyalinization, and extensive myxoid material. (Level of Difficulty: Beginner.).

[Atypical presentation of ruptured aneurysmal right sinus of Valsalva with severe aortic insufficiency]

Aneurysm of the Sinus of Valsalva (ASV) is a rare abnormality and affects less than 0.1% of the general population. We describe the case of a 37-year-old woman with a clinical picture characterized by dyspnea, palpitations, and syncope of 6 years of evolution. The echocardiographic study revealed a right ASV with a sub pulmonary interventricular perforation of 8mm and producing a regurgitant jet into the right ventricle, causing dilatation of the right ventricular outflow tract, pulmonary artery, and severe aortic insufficiency Carpentier DI. The patient underwent successful repair of the defect and interventricular perforation, and valve replacement was not necessary. Timely echocardiographic diagnosis and early surgery are the main predictors that make the difference between an excellent outcome and certain death.

Repair of Giant Sinus of Valsalva Aneurysms

Sinus of Valsalva aneurysm (SVA) is a rare, abnormal dilation of the aortic root. Although often asymptomatic, SVAs can be manifested with a variety of symptoms, including rupture, which is a highly lethal condition. Most SVAs are small, and most patients present with aneurysm in a single coronary sinus. We describe the case of a 69-year-old man presenting with ventricular tachycardia cardiac arrest and 2 SVAs, a giant one arising from the right coronary sinus and a smaller one coming from the left coronary sinus. Included in the case presentation is our operative repair video.

Ruptured sinus of Valsalva aneurysm with dynamic aortic regurgitation

The ruptured sinus of Valsalva aneurysm (SVA) can present with dynamic aortic regurgitation (AR). Hemodynamic changes elicited by induction of general anesthesia can lead to dynamic AR in setting of ruptured SVA. Perioperative echocardiography is critical in understanding the etiology of AR and in guiding surgical decision-making. If the aortic valve is structurally normal, AR may resolve following patch repair of the SVA rupture defect. Conventional measures of assessing AR severity are not accurate with continuous left-to-right flow across a ruptured SVA.

Multimodality delineation of a fistulous ruptured sinus of Valsalva aneurysm: a teaching case report

Background

Ruptured sinus of Valsalva (SOV) is a rare cardiac anomaly with poor prognosis if untreated. Early diagnosis with accurate delineation of its anatomy is critical for timely treatment and choice of surgical vs. percutaneous intervention. Here we report a case of fistulous rupture of SOV; the preoperative multimodality studies including echocardiography, cardiac magnetic resonance and cardiac catheterization provided teaching and learning points.

Case summary

A 48-year-old man with history of heart murmur and hypertension presented with a 5-day history of shortness of breath and peripheral oedema. He was diagnosed with rapid atrial flutter. The transthoracic and transesophageal echocardiography showed severe biventricular systolic dysfunction with a left-to-right shunt from ruptured SOV. The colour Doppler by transthoracic and transesophageal echocardiography and cardiac magnetic resonance revealed a swaying shunt flow exiting in direction to the right atrium (RA) and basal right ventricle (RV) during systole and diastole with no myocardial scaring. The left and right heart catheterization showed elevated right-sided pressures, pulmonary capillary wedge pressure, and left ventricular end-diastolic pressure. There was no difference in O2 saturation between venae cavae and RA but a misleading step-up in O2 saturation between RA and RV. Owing to rupture anatomy with uncertainty, the patient underwent surgical intervention. The ruptured SOV tunnelled through the base of tricuspid annulus to the RA very close to the basal RV.

Discussion

Even with multimodality studies it can still be challenging to delineate the anatomy of a ruptured SOV without uncertainty preoperatively.

Surgical Repair of a Sinus of Valsalva Aneurysm

A surgically challenging case of an unruptured Sinus of Valsalva aneurysm (SoVA) with severe aortic regurgitation (AR) due to cusp prolapse is presented. Sinus reconstruction with a patch cut out from the sinus portion of a Gelweave Valsalva graft (Terumo Vascutek) was performed. Intraoperative measurements showed insufficient effective height of the right coronary cusp; therefore, cusp plication and pericardial patch augmentation of the right coronary cusp were performed with satisfying result.

To Treat or Not to Treat? This Is the Question… About the Incidental Finding of Double Sinus of Valsalva Aneurysm in A 91-Year-Old Woman

Sinus of Valsalva aneurysm is a very uncommon clinical finding and often requires emergency surgery due to its high risk of rupture. This educational text reports the case of a 91-year-old Italian women who was incidentally discovered to have a huge double aneurysm of the sinuses of Valsalva.

Case Report: Right Heart Failure Mistaken for Obesity-A Fault of Telemedicine

As a result of the COVID-19 pandemic, telemedicine has become an important branch of healthcare worldwide. Apart from their undeniable advantages, the virtual visits lack physical examination, which can lead to important diagnostic mistakes. We hereby present a case of a pediatric patient whose weight gain, initially attributed to a sedentary lifestyle was, in fact, due to sub-acute right heart failure in the context of a ruptured sinus of Valsalva aneurysm. The condition was not diagnosed until the patient presented at the emergency. The boy was successfully treated with two percutaneous interventions and returned to his previous stature.

Two giant sinus of Valsalva pseudoaneurysms as a casual finding

BACKGROUND

Pseudoaneurysms of the sinus of Valsalva are infrequent cardiac pathologies that usually involve a single sinus.

MATERIAL AND METHODS

We present a case of a 63-year-old male who was diagnosed with ascending aortic aneurysm during a routine echocardiogram.

CONCLUSION

We report here a patient with giant pseudoaneurysms of two sinuses of Valsalva who successfully underwent a sinus of Valsalva reconstruction.