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

Table 1 Comparison table of noninvasive imaging modalities used in the diagnosis and assessment of sinus of Valsalva aneurysms

Imaging modalities	General information	Strengths	Limitations
TTE	The first imaging modality of choice for diagnosis of SoVA	Possess > 90% accuracy for detecting SoVA. It is additionally safe, cost-effective, portable, and more widely available	Can sometimes incorrectly detect rupture site
TEE	Required as additional imaging in up to 25% of cases to further characterize the anatomy of the sinuses and their surrounding structures	Possesses better acoustic window and higher resolution, which facilitates more accurate characterization of the aneurysm and its surrounding structures	Contraindicated in patients with esophageal disease including known stricture, varices, diverticula, or tumors
ECG-gated MDCT	An acquisition technique that triggers a scan during a particular portion of the cardiac cycle	Provides high spatial resolution, elimination of motion artifacts, and improved temporal resolution in the nonemergent setting. Additionally, gated CT’s ability to obtain multiplanar reformations provides superior anatomic delineation and can simultaneously assess the coronary arteries	More cost prohibitive. Additionally, retrospective ECG gating is needed to assess ventricular function and valvular motion, which carries a high radiation burden
Cardiac MRI	Plays an important role in SoVA assessment and is particularly important in the assessment of biventricular function	Gold standard imaging technique for SoVA due to its lack of ionizing radiation, better temporal resolution, ability to quantify ventricular function and aortic regurgitant fraction, and provides an assessment of wall motion abnormalities	More cost prohibitive

TTE: Transthoracic echocardiogram; SoVA: Sinus of Valsalva aneurysm; TEE: Transesophageal echocardiogram; ECG-gated MDCT: Electrocardiographic-gated multi detector computed tomography; CT: Computed tomography; ECG: Electrocardiogram; MRI: Magnetic resonance imaging.

Table 2 Comparison table of treatment options for sinus of Valsalva aneurysms

Interventions	Recommendations	Advantages	Disadvantages
Medical management	Insufficient for definitive treatment. Blood pressure control with antihypertensives such as angiotensin-converting enzyme inhibitors, beta-blockers, or calcium channel blockers to reduce aortic wall stress should be used as a temporary measure until definitive surgical repair or transcatheter closure can be done	Reduces the chances of rupture for cases of unruptured SoVAs	Not definitive treatment
Surgical repair	Surgery remains the definitive treatment for SoVAs. Recommended for symptomatic, large, or rapidly progressive aneurysms and all ruptured aneurysms. The 2010 American Guidelines for Thoracic Aortic Disease recommend considering surgical repair for aneurysms greater than 5.5 cm, greater than 5 cm in patients with BAVs, greater than 4.5 cm in the setting of connective tissue disease, or a yearly growth rate that exceeds 0.5 cm	Can address concurrent cardiac issues such as VSDs or aortic valve dysfunction	Higher risk for complications such as bleeding, infection, or heart failure. Additionally, surgical repair prolongs hospital stay and recovery times compared to TCC
Transcatheter closure	Emerging minimally invasive technique used to treat both ruptured and unruptured aneurysms	Advantages include reduced surgical risks, avoiding heart surgery, and shortened hospital length and recovery times	Has potential complications such as residual shunt, embolization, or device malposition, which are generally manageable

SoVA: Sinus of Valsalva aneurysm; BAVs: Bicuspid aortic valve; VSDs: Ventricular septal defects; TCC: Transcatheter closure.