This document provides an overview of sinus of Valsalva aneurysm (SOVA). Key points include: - SOVA is a thin-walled bulge that originates from the aortic sinuses, most commonly the right sinus. It can rupture into the right heart chambers. - Presentation depends on rupture status - ruptured SOVA causes a continuous murmur while unruptured can cause arrhythmias or embolism. Imaging helps confirm diagnosis. - Surgery is the standard treatment, involving a median sternotomy, cardiopulmonary bypass, and patch closure of the defect from inside the aorta and heart chambers. Device closure is also possible. Outcomes are generally good but

1. SINUS OF VALSALVA ANEURYSM
Moderator- Dr.RV KUMAR
Presenter- Dr.Jyotindra Singh

2. INTRODUCTION
Thin walled, saccular or tubular
outpouchings, usually always in the
right sinus or adjacent half of the
noncoronary sinus.
Generally have an - Intracardiac course
May protrude into the pericardial space and
they may rupture into the right (or rarely left)
heart chambers to form ---
Aorta-cardiac fistula.
5 times higher in Asian countries.
Male preponderence – 4:1
0.15-1.5% surgeries correspond to SVA repair

3. HISTORICAL ASPECT
1839 -1st description by Hope
1840- 1st important paper published by Thurman
1949- Jones and Langley -the subject of congenital and acquired
lesion .
1951- 1st diagnosis of rupture during life by Venning
1956- 1st. successful repair with CPB at Mayo Clinic using CPB.
1957-Morrow & colleagues –closed ruptured SOVA using mild
hypothermia
SAKAKIBARA & KONNO
- Studied association with VSD & AR
- First to provide comprehensive classification

4. AORTIC ROOT- ANATOMY
Young
adults
AA>STJ
Adults
AA = STJ
Elderly
AA<STJ

5. ROOT ANATOMY
.
The 2 trigones underneath the commissures of
the noncoronary leaflet are fibrous structures,
whereas the other underneath the commissure
between the right and the left leaflets is mostly
a muscular structure.

6. Anatomic and Echocardiographic Relationship
Between the Components of the Normal Aortic Root
120 degree - LAX
Annulus
Sinuses
Systole
ST junction
Tubular aorta
Diastole

7. SINUS OF VALSALVA
ring.

8. SINUS OF VALSALVA
3 sinuses named after- Antonio Valsalva.
Provide space behind the open aortic leaflets so
that the leaflets do not occlude the coronary artery
orifices.
Secondly, this space favours the development of
eddy currents behind the leaflets when they are
open.
Magnetic resonance imaging has shown- in aiding
leaflet opening through the creation of a lowpressure system by means of the Venturi effect.
In valve sparing aortic valve surgery,
maintenance or recreation of the sinuses has been
beneficial in terms of normal leaflet movement and
valve durability

9. MORPHOLOGY
1 Separation of the aortic media of the
sinus from the media adjacent
to the hinge line of the AV valve
cusp .
Results from the absence of normal
aortic elastic tissue and media in two
region.
2
Congenitally weak area gradually
gives way under aortic pressure to
form an aneurysm.
3
The aneurysm appears an excavation
of the sinus which protrudes into the
underlying cardiac chamber.

11. CONGENITAL
Connective tissue disordersRheumatoid arthritis,
Ehlers-Danhlos syndrome,
Marfan’s syndrome,
Klippel Feil syndrome,
Turner’s syndrome,
Trisomies 13 and 15,
Loeys-Dietz syndrome,
Arachnodactyly,
Osteogenesis imperfecta.
ACQUIRED
Infectious diseases –
bacterial endocarditis,
syphilis, and tuberculosis;
Degenerative conditions
atherosclerosis
cystic medial necrosis;
Injury from deceleration trauma.
Iatrogenic pseudoaneurysms
hematoma formation after AVR
removal of aortic valve calcifcations

12. ACQUIRED

14. Type I: the aneurysm originates in the left portion of the right sinus, protrudes
forward and ruptures into the right ventricle near the pulmonary valve.
The concurrent presence of VSD under the pulmonary valve is frequent.
Type II: the aneurysm originates in the mid portion of the right sinus, protrudes and
ruptures in the right ventricle. A concurrent VSD is uncommon.
Type III: the aneurysm originates in the mid portion of the right coronary leaflet and
protrudes towards the tricuspid valve. It often ruptures into the right atrium and
sometimes into the right ventricle, just below the septal leaflet of the tricuspid valve.
VSD is rarely encountered.
Type IV: the aneurysm originates in the right portion of the non-coronary leaflet and
ruptures into the right atrium. A combined VSD is uncommon.

15. Congenital Heart Surgery Database Committee
of the Society of Thoracic Surgeons

17. RSOVA-Variants
Leftward portion of sinus
WINDSOCK projecting into the
adjacent RVOT just below the
pulmonary valve.
Arising CENTRALLY
project in the outlet portion of the
RV aspect of the ventricular septum
RIGHTWARD
Entering RV beneath the parietal band in
the region of Membranous septum

18. Non coronary sinus- VARIANTS
Non coronary sinus
originate from –ANTERIOR PORTION
---- Project into RIGHT ATRIUM
---- Rarely into RV or RA+ RV,
muscular ventricular septum.
POSTERIOR PORTION
RUPTURE INTO PERICARDIUM

19. Associated cardiac anomalies - VSD
Prevalence – 30 to 50 %
Incidence higher in Rt.sinus
Left third of right aortic sinusJUXTA – ARTERIAL
RIGHT THIRD – conoventricular /peri
membranous
Centrally – Juxta aortic / outlet portion
of the septum.
Hinge line of aortic leaflet separates
aneurysm from VSD
Supracristal VSD & RSOVA
Incomplete fusion of the truncal swellings at the
time of the division of the common truncus
from the bulbar septum during the 5th week of
embryogenesis

20. VSD - CLASSIFICATION
Type-I - VSD is present immediately below the commissure of
the left & right semilunar cusp of pulmonary valve .Aneurysm
ruptures into the RVOT forming aortico –right ventricular fistula.
Type-II- VSD rests on the crista supraventricularis,not in
contact with the tricuspid or pulmomary valves.
Type-III- VSD lies just below crista supraventricularis and the
corresponding sinus of valsalva.
Type –IV – VSD rests on the paramembranacea

21. OTHER ANOMALIES
Aortic regurgitation
results from prolapsed
aortic cusp
Bicuspid aortic valve
leading to AR.
Pulmonary stenosis
Aortic coarctation
PDA
ASD
Subaortic stenosis
TOF

22. ANEURYSM RUPTURE
Ruptured aneurysms originate
most frequently from the right
coronary sinus (65–85%),
Less frequently from the
noncoronary sinus (10–30%), and
Rarely from the left coronary sinus
( 5%)
The right ventricle is the most
common receiving chamber (about
80–90%), due to rupture of either
right or noncoronary SVA

23. RUPTURE
RIGHT CORONARY SINUS
Develop localized “
WINDSOCK ”
Rupture into adjacent low pressure chamber
INTRA CARDIAC FISTULOUS PORTION
NIPPLE LIKE
projection into cardiac
chamber with one or more points of rupture at its apex
Non coronary sinus origin
- have no
WINDSOCK deformity , direct fistulous
communication between aortic sinus & heart
Left sinus origin
aneurysm
– Extra cardiac

24. ANEURYSM RUPTURE
SITES OF RUPTURE
ASIANS
Non- Asians
RIGHT ATRIUM
13
35
RIGHT occur.
VENTRICLE
84
57
RV + RA
<1
<1
LEFT ATRIUM
<1
<1
LEFT VENTRICLE
<1
2
RA+ LA+ LV
<1
<1
VENTRICULAR SEPTUM
<1
<1
PULMONARY TRUNK
<1
<1
RV + Pulmonary trunk
<1
<1
PERICARDIUM
<1
2

25. Presentation
SOVA clinically presents based on
Depending on the size of the aneurysm,
the rapidity with which it ruptures,
the cardiac chamber with which it communicates
RUPTURED SOVA
20% no symptoms develop.
45%- gradual onset of effort dyspnea
35% - acute symptoms
sudden breathlessness & pain
Pain- precordial/ epigastric
Sudden death
precipitated by – heavy exertion/ IE / Marfan syndrome.

26. UNRUPTURED ANEURYSM
- Tricuspid valve dysfunction
- RVOT obstruction
- Severe MI – by compressing
right or left coronary artery.
- Conduction abnormalities
- Embolization from unruptured
aneurysm.
ST-elevation in leads V1–V3

27. JVP in Ruptured aneurysm
Rupture into the Right ventriclethe severe diastolic ventricular
volume-overload causes
Obliteration of the y-descent
Rupture into the right atrium
obliterates the x-descent.
The high Right atrial pressureEarly tricuspid opening
Premature v-wave,
High peaked a-wave
with a fourth heart sound.

28. Ruptured aneurysm
Sudden appearance of a continuous
murmur in an otherwise healthy individual.
Heard at a maximum at the lower sternal
border or xiphoid.
Diastolic accentuation of this murmur is
an important sign to differentiate ruptured
sinus from PDA or arteriovenous fistula.
Systolic suppression of the murmur is
caused by both mechanical narrowing of
the fistulous tract during systole as well as
the probable
Venturi effect created by the rapid ejection
of blood past the aortic origin of the fistula

29. SUDDEN CARDIAC DEATH
Tamponade
Myocardial ischemia,
Conduction disturbances and/or
arrhythmias.
Rupture into the pericardial
space, a very rare complication
(2% of noncoronary SVA
ruptures), almost invariably leads
to fatal cardiac tamponade
Rupture causes compression of
the ostium of the left main
coronary artery, resulting in
myocardial ischemia and
arrhythmic death

30. ECG
ECG showing sinus tachycardia with 1st degree AV block and right bundle branch block.
Compression of the His bundle occurs when the
ruptured SVA penetrates the base of the
interventricular septum and results in atriovenricular
Ventricular tachycardias arising from the aortic
sinus of Valsalva: An under-recognized variant of
left outflow tract ventricular tachycardia

32. X RAY
It is uncommon to find the aneurysm
abnormality on x ray as they are
intracardiac.
However, the evidence of aortic
atherosclerosis is a clue to the
etiology as evidenced in this patient.
Rarely these aneurysms can cause
heart border abnormalities depending
upon the cusp involved.
Marked cardiomegaly can be
visualized if aortic root dilation and
aortic insufficiency are present

33. IMAGING GUIDELINES

35. 35

37. AORTOGRAM
Right-sided pressures were elevated
with a right atrial pressure of 12 mmHg,
occur.
Pulmonary artery pressure of 47/31
mmHg with a mean of 37 mmHg, a
pulmonary wedge pressure of 20 mmHg
and a left ventricular end-diastolic
pressure is 24 mmHg.
There was a significant 14% rise in
oxygen saturation between the right
atrial and vena caval oxygen
saturations.
A single injection was done at the aortic
root which demonstrated a
communication between the origin of the
right sinus of Valsalva into the right
atrium (RA), with eventual opacification
of the right atrium, right ventricle (RV)
and pulmonary arteries. -

39. CT vs CMR
The advantages of performing MR imaging in
the setting of a known or suspected Valsalva
sinus aneurysm include the
-evaluate the LV hemodynamic pattern,
- identify aortic regurgitation and quantify
aorto-cardiac shunt or fistulous blood flow.
CT is less time consuming and the preferred
investigation compared to MRI in case of
acute setting of aneurysmal rupture
Conventional angiography is the
gold standard and can be used for both
diagnostic and therapeutic purposes.

40. Indications for Surgery

41. Indications for surgery
Enlargement beyond 5.5 cm,
Progression of greater >1.0 cm/year.
Aortic regurgitation from distraction of
the commissural posts with ventricular
enlargement
Unruptured aneurysms encroaching on
nearby structures, causing myocardial
ischemia, or having the potential to
rupture warrant repair.
Family history of aortic dissection or
rupture.
Asymptomatic patients – Serial followup . If high likelihood of progressive
increase in size and the possibility of
rupture or endocarditis.

42. STEPS OF SURGERY
Approach is by a median
sternotomy using
cardiopulmonary bypass.
The arterial cannula is placed
distally in the ascending aorta.
Bicaval venous cannulation using
right angle cannulas should be
used.
A moderate degree
hypothermia,e.g. 28°C, is
appropriate.
CARDIOPLEGIA- Retrograde

43. STEPS OF SURGERY
A transverse aortotomy is performed,
and the root anatomy assessed.
An oblique right atriotomy is performed
next, allowing for identification of both
ends of the aneurysm or of the
fistulous tract in case of rupture .
In case of protrusion or rupture into the
right ventricle, exposure can be
obtained through a right atriotomy or a
limited ventriculotomy .
When the fistulous tract or
diverticulum is in the right ventricular
infundibulum, the lesion can also be
exposed through a transverse
pulmonary arteriotomy.

44. Single/Double patch repair
The defect must be repaired through the
aortic root, using a patch of autologous or
bovine pericardium to exclude the aortic
inlet into the aneurysm.
Primary closure predisposes to a higher risk
of recurrence (as high as 20%) or aortic
valve regurgitation from deformation of the
root. - CONDEMNED
The ventricular or atrial aspect of the fistula
can be closed primarily,
a patch should be used to incorporate
closure of a coexisting ventricular septal
defect
Great care should be taken in avoiding the
atrioventricular conduction system at the
time of VSD closure.

46. RSOVA + VSD
Aneurysm is in Right ward position of
Right sinus - Perimembranous VSD
RIGHT ATRIAL APPROACH with
detachment of antr & septal leaflet of TV
Leftward portion of the Right sinus-
Vsd is juxta arterial - approach is through
the RV or pulmonary trunk.
Combined Approach- Aortic & RV
pulmonary trunk or right atrial approach.

47. RSOVA + VSD
Thinned out windsock containing one or
more perforation – resected creating a large
defect in Rt. sinus of valsalva.
Defect separated from VSD by hinge line of right
aortic cusp.

48. RSOVA to RA ,No VSD
Origin- usually non coronary sinus but
occasionally from right coronary sinus.
Approach- Aorta alone or right atrium.
Clamp placed across windsock.
A coexisting VSD is always sought.
Windsock is excised –based on hinge
line of valve cusp.
Windsock is narrow & bordering edges
are of good quality- direct closure

49. Unruptured sinus of valsalva aneurysm
Approach through ascending aorta.
CPB- through single canula in RA.
Venting catheter in LA
Cardioplegia
Aorta – opened transversely
Site of origin of aneurysm defined.
Orifice closed with pericardial / dacron
patch

51. SOVA- RESULTS

52. Complications
Most patients survive the early post op period.
Hospital mortality – max. 5% reported.
Severe AR with marked LV enlargement is a risk
factor for premature death in late postop period.
Direct closure – 20 to 30 % prevalence for
reoperation for reoperation for recurrence of the
fistula.
Heart block occurs in 2 % to 3% of patients.

53. DEVICE CLOSURE

54. DEVICE CLOSURE