What is the management approach for a sinus of Valsalva aneurysm or rupture?

Management of Sinus of Valsalva Aneurysm

Immediate Surgical Intervention Required

All ruptured sinus of Valsalva aneurysms require urgent surgical repair, and unruptured aneurysms causing moderate-to-severe aortic regurgitation, conduction abnormalities, myocardial ischemia, or compression of cardiac structures also warrant surgical correction. 1

Indications for Surgery

Ruptured Aneurysms:

• Surgical repair is mandatory for all ruptured aneurysms regardless of symptoms, as rupture carries the highest mortality and morbidity risk 1
• Do not delay surgery in patients with acute rupture or progressive heart failure—urgent intervention improves survival and preserves cardiac function 1
• Rupture typically presents with acute left-to-right shunt, aortic runoff, and cardiac decompensation 2

Unruptured Aneurysms:

• Surgery is indicated when causing moderate-to-severe aortic regurgitation to prevent progressive ventricular dysfunction 1
• Repair is warranted when aneurysms encroach on nearby structures, cause myocardial ischemia, or have potential for rupture 3
• Aneurysms causing conduction abnormalities or compression of cardiac structures require repair 1

Diagnostic Approach

Transthoracic echocardiography (TTE) with Doppler color flow imaging is the first-line diagnostic modality 1:

• TTE can diagnose the aneurysm, document rupture with color Doppler showing the fistulous communication, and assess aortic valve function and ventricular function 1
• Echocardiography provides all necessary details for diagnosis 4

Advanced Imaging:

• Transesophageal echocardiography (TEE) is reasonable for thoracic aortic aneurysms and can better define anatomy when valve-sparing intervention is considered 5
• CT or MRI is required to adequately visualize the entire aorta and identify all affected segments 1
• Aortic root dilatation is suspected when diameter exceeds 40 mm in males or 36 mm in females, or when indexed diameter/BSA exceeds 22 mm/m² 1

Surgical Technique

Dual Exposure/Patch Repair Strategy:

• Combined aortocameral approach is recommended, with sandwich patch technique for repair 2
• Simple or Teflon pledgetted direct suturing can be used (58% of cases), or patch repair (40% of cases) 4
• Dual exposure/patch repair strategy is specifically advocated in ruptured cases 4

Concomitant Procedures:

• Aortic valve replacement is needed only in patients with severe degenerative changes 2
• Aortic valve resuspension may be performed for moderate aortic regurgitation 4
• Associated ventricular septal defects should be repaired during the same operation 4, 6

Expected Outcomes

Operative Results:

• Early mortality is low at 1.9-2% in contemporary series 4
• Operative mortality in recent decades has improved to approximately 11.7% 2
• Surgical success rate exceeds 95% with excellent long-term survival 7

Long-term Follow-up:

• Survivors demonstrate excellent symptom-free long-term outcomes, with most patients in NYHA Class I or II 4
• Reoperation rate is low (approximately 5-6% due to suture dehiscence), which can be successfully managed with patch repair 4
• Complete heart block requiring permanent pacemaker occurs in approximately 2% of cases 4

Common Pitfalls and Caveats

Anatomic Considerations:

• The right coronary sinus is most commonly involved (70-85% of cases), followed by noncoronary sinus (15-25%), with left coronary sinus rarely affected 4, 6, 7
• Rupture into the right ventricle occurs most frequently (70%), followed by right atrium (20-30%) 6, 7

Associated Cardiac Anomalies:

• Ventricular septal defect is present in 40-65% of cases and must be identified preoperatively 4, 6
• Aortic regurgitation occurs in 30-50% of patients and requires assessment of severity 4, 7
• Progressive aortic regurgitation develops in 20-30% of patients with aortic root aneurysms 1

Infectious Complications:

• Infective endocarditis risk is elevated, particularly in unrepaired aneurysms 1
• Acquired aneurysms may be caused by infections including syphilis, bacterial endocarditis, or tuberculosis 3