Summary: A 29-year-old male presents with chest pain and worsening shortness of breath with minimal
exertion. A computed tomography angiography (CTA) of the coronary vessels was
ordered for further evaluation.
Sinus of Valsalva aneurysm
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.
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
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
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.
- Bricker AO, Avutu B, Mohammed TL, et al. Valsalva sinus aneurysms: Findings at CT and MR imaging. Radiographics. 2010;30:99-110.
- White CS and Plotnick GD. Sinus of Valsalva aneurysm. Radiology. 2001;219:82-85.