Diagnosis and treatment options for sinus of Valsalva aneurysms: A narrative review

Abstract

Sinus of Valsalva aneurysm (SoVA) is a rare cardiac defect that may be congenital or acquired. It is characterized by abnormal dilatation of the aortic root due to a weakened elastic lamina at the junction of the annulus fibrosus and the aortic media. SoVAs are present in approximately 0.09% of the general population and comprise up to 3.5% of all congenital cardiac defects. It is usually found incidentally on cardiac imaging, with a higher incidence observed in the Western populations and a male-to-female ratio of 4:1. A transthoracic two-dimensional echocardiogram is the initial diagnostic test of choice, which may reveal the characteristic "windsock deformity" that clinches the diagnosis. Other imaging modalities, such as transesophageal echocardiography and cardiac computed tomography angiography, help provide more extensive details of the aneurysm and its adjacent structures. Management options for ruptured and unruptured SoVA include surgical repair or transcatheter closure, which serves as a game-changing development in treatment. This article aims to provide background information on the epidemiology, pathophysiology, diagnosis, and recent advancements over the past decade in the management of SoVAs.

Keywords: Atrial septal defect; Bicuspid aortic valve; Cardiac computed tomography; Cardiac magnetic resonance imaging; Echocardiography; Pulmonary stenosis; Sinus of Valsalva aneurysm; Ventricular septal defect.

Figure 1

Proposed diagnostic algorithm for the assessment of suspected sinus of Valsalva aneurysm. Transthoracic echocardiogram is first line, followed by transesophageal echocardiogram if findings are not diagnostic or equivocal for the aneurysm. Cardiac computed tomography (CT) or magnetic resonance imaging (MRI) is used for further assessment after confirmation of diagnosis on echocardiography. MRI has a higher temporal resolution than CT and offers excellent soft tissue contrast and anatomical delineation. As such, MRI is preferred over CT for concurrent valvular assessment and flow information. TTE: Transthoracic echocardiogram; VSD: Ventricular septal defect; ASD: Atrial septal defect; SoVA: Sinus of Valsalva aneurysm; TEE: Transesophageal echocardiogram; CT: Computed tomography; MRI: Magnetic resonance imaging.