Massive sinus of Valsalva aneurysm with an associated bicuspid aortic valve: A rare clinical image

A 52-year-old male with no significant medical history presented to the emergency department with a two-week onset of dry cough, rhinorrhea, and worsening dyspnea on exertion. An electrocardiogram on admission revealed left ventricular hypertrophy with repolarization abnormalities. Due to concerns for new-onset heart failure, a complete two-dimensional transthoracic echocardiogram (TTE) was performed, which revealed a circular fine structure within the left atrium, suggestive of an aneurysm (Figure 1a). To further investigate the findings on TTE, a transesophageal echocardiogram (TEE) was subsequently done, revealing a sinus of Valsalva aneurysm with an associated bicuspid aortic valve (Figure 1b). The patient underwent surgical repair of the unruptured aneurysm using a patch cut from a Valsalva aortic prosthesis Gelweave Valsalva^TM graft (Terumo Vascutek). The postoperative course was uncomplicated, and the patient completely recovered after three months.

Figure 1

Sinus of Valsalva aneurysm, or SOVA, is a cardiac defect that is congenital or acquired with an estimated incidence of approximately 0.09 % in the general population.¹ It is commonly associated with other congenital heart anomalies such as ventricular septal defects, bicuspid aortic valve, and pulmonary stenosis.^1,2 They originate from the right coronary sinus in 70 to 90 percent of cases, followed by the noncoronary sinus (10%-25%) and the left sinus (<5%).³ Clinical presentation may be asymptomatic or may include acute rupture that clinically manifests with chest pain, dyspnea, palpitations, and cardiac murmurs.^1-3 Cardiac computed tomography or magnetic resonance imaging may be used to aid in the diagnosis.³ However, TEE is preferred for anatomical delineation of aneurysmal origination, which will appear on two-dimensional imaging as a thin-walled mobile structure that is circular in the short axis.^2,3 Surgical repair remains the preferred method of treatment.^3,4 In patients with a ruptured SOVA, transcatheter closure devices are an acceptable alternative in those with suitable anatomy and high risk for cardiac surgery.^2,5