Applied Radiology

Diagnosis

Sinus of Valsalva aneurysm

Findings

Coronary CTA images demonstrate aneurysmal dilation of the noncoronary sinus of Valsalva. The aorta measured 7.4 x 5.6 cm at the level of the sinus of Valsalva on multiplanar reconstruction images (not shown). The remainder of the aorta is normal in caliber. The coronary arteries are widely patent and without anatomic variants.

Discussion

Sinus of Valsalva aneurysms are rare and may be congenital or acquired due to infection, degeneration, or traumatic injury. Congenital aneurysms are postulated to arise secondary to weakness of the elastic lamina at the junction of the aortic media and annulus fibrosus, most commonly seen in patients with Marfan Syndrome and Ehlers-Danlos Syndrome. Infectious causes include syphilis, bacterial endocarditis, and tuberculosis.

The sinuses of Valsalva are 3 small dilations of the aortic root, which are located between the annulus of the aortic valve and the sinotubular junction. The left coronary sinus gives rise to the left coronary artery, the right coronary sinus gives rise to the right coronary sinus, and the noncoronary sinus does not have an associated coronary artery. The sinuses are postulated to allow space for the aortic leaflets to open during systole without occluding the ostia of the coronary arteries.

Sinus of Valsalva aneurysms occur in patients of all ages with a 2:1 male predominance. Aneurysms are most common within the right coronary sinus (~72%) with the noncoronary sinus (22%) and left coronary sinus (6%) involved less frequently. Aneurysms may be discovered before or after rupture. Unruptured aneurysms may be discovered incidentally or due to symptoms from aortic regurgitation or mass effect on adjacent structures. Ruptured aneurysms result in an aortocardiac shunt and present with symptoms of progressive congestive heart failure, including dyspnea, chest pain, volume overload, and hemodynamic compromise. Due to the high incidence of involvement of the right coronary sinus, rupture most commonly occurs in the right ventricle or right atrium with the left atrium, left ventricle, pulmonary artery, and pericardium being involved much less often.

The diagnosis of a sinus of Valsalva aneurysm may be made by echocardiography, CT, or magnestic resonance imaging. The aneurysm should be saccular and originate from above the aortic annulus with a normal sized aortic root and ascending aorta.  In addition, radiographic abnormalities such as cardiomegaly and pulmonary vascular congestion may be seen in ruptured cases due to hemodynamic changes.

Both ruptured and nonruptured sinus of Valsalva aneurysms may have fatal complications, so prompt diagnosis is important. Treatment consists of surgical repair, usually a Bentall procedure, which consists of composite graft replacement of the aortic valve, aortic root, and ascending aorta. The prognosis for surgically treated aneurysms is very good with 10-year survival rates of 90% to 95%. There are also reports of percutaneous transcatheter closure of ruptured sinus of Valsalva aneurysms, utilizing an occlusion device with promising early results.

1. Bricker AO, Avutu B, Mohammed TL, et al. Valsalva sinus aneurysms: Findings at CT and MR imaging. Radiographics. 2010;30:99-110.
2. White CS and Plotnick GD. Sinus of Valsalva aneurysm. Radiology. 2001;219:82-85.