Aneurysm of the sinus of Valsalva

A 47 year-old female of south Asian origin presented with acute pulmonary oedema. Her background included previous investigation for bilateral lung nodules (which remain of uncertain aetiology) and complete heart block leading to dual chamber permanent pacemaker implantation one year previously. A transthoracic echocardiogram identified an unruptured aneurysm of the right coronary sinus of Valsalva, and severe aortic regurgitation. An echodense structure suspicious of thrombus was noted inside the aneurysm. The images show an aneurysm of the right coronary sinus of Valsalva on the transthoracic echocardiogram and on a subsequent transoesophageal echocardiogram (Figs. 1, 2). Aneurysms of the sinus of Valsalva are rare, with a prevalence of 0.09% in a large autopsy series [1]. Among those undergoing open heart surgery, the incidence ranges from 0.14% to 0.96% [1], with higher frequencies in male and in Asian patients. Congenital aneurysms caused by weakness at the junction of the aortic media and the annulus fibrosus occur more commonly than acquired aneurysms, which are typically secondary to disease processes that involve the aortic root (e.g. atherosclerosis, syphilis, endocarditis, cystic medial necrosis, and chest trauma) [2]. Overall, about 65–85% of the aneurysms occur in the right coronary sinus, 10–30% in non-coronary sinuses and less than 5% arise from the left coronary sinuses [3]. Sinus of Valsalva aneurysms may remain clinically silent for many years. About half are associated with aortic regurgitation. Symptoms are