Successful device closure of a ruptured sinus of Valsalva aneurysm presenting with acute heart failure.

To cite: Mahajan K, Asotra S, Negi P, et al. BMJ Case Rep Published online: [please include Day Month Year] doi:10.1136/bcr-2015212883 DESCRIPTION A sinus of Valsalva aneurysm (SVA) is an uncommon cardiac anomaly that can be congenital or acquired. SVAs were present in 0.09% of cadavers in a large autopsy series and ranged between 0.14–0.23% in a Western surgical series. A congenital SVA is usually clinically silent but may vary from a mild, asymptomatic dilation detected in routine two-dimensional echocardiography, to symptomatic presentations related to the compression of adjacent structures or intracardiac shunting caused by rupture of the SVA into the right side of the heart. Approximately 65–85% of SVAs originate from the right sinus of Valsalva, while SVAs originating from non-coronary (10–30%) and left sinuses (<5%) are exceedingly rare. The most common complication is rupture into the atrium or ventricle, and, very rarely, towards the left chambers, causing left-to-right shunting or aortic valve insufficiency with congestive heart failure and the need for urgent surgical resolution. Although open-heart surgery with or without aortic valve replacement remains the treatment of choice, trans-catheter device closure of a ruptured SVA has been successfully performed. So far, around 136 cases of device closure of ruptured SVAs have been reported in the literature. For an asymptomatic unruptured SVA, there is no consensus regarding management. Most large surgical series have advocated early surgical repair even if the patient is asymptomatic, while Vural et al proposed that patients with unruptured, stable aneurysms should be anticoagulated, followed at 6-month intervals, and then repaired if symptoms develop or the size of the sinus is >50% of the average size of the other two normal Valsalva