A sinus of Valsalva aneurysm is a rare form of aortic dilatation, statistically more common in the young population. Rupture of a sinus of Valsalva aneurysm into the right heart chambers causes volume overload and a spectrum of clinical symptoms. This condition requires urgent surgical treatment. We present the case of an elderly patient with a rupture of noncoronary sinus of Valsalva aneurysm into the right atrium. Due to the poor quality of the aortic tissue, we opted for sinusoplasty instead of a Bentall de Bono or David procedure. Two bovine patches were implanted and reinforced with a TachoSil® hemostatic patch. This approach led to a shorter operative time and a favorable postoperative outcome.

The incidence of sinus of Valsalva aneurysms in the general population is estimated at 0.09%. Approximately 70% of all sinus of Valsalva aneurysms occur in the right coronary sinus, while around 25% arise from the noncoronary sinus [1]. Due to their often asymptomatic nature, these aneurysms are frequently diagnosed only after rupture into a cardiac chamber [2]. Statistically, the most common site of rupture is the right ventricle, followed by the right atrium [3]. Ruptures are most frequently observed in patients between 20 and 40 years of age, with rare occurrences in the elderly population [4].

We present a case of a 77-year-old patient with a history of partial left nephrectomy due to renal cancer, currently undergoing immunotherapy, and long-term follow-up for aortic root dilatation. The patient was admitted to the hospital with worsening symptoms of heart failure over the preceding month, including dyspnea, peripheral edema, and significant weight gain. On admission, the patient reported dyspnea with minimal exertion. Physical examination revealed marked lower limb edema, ascites, and auscultatory crackles over both lung fields. 

Echocardiography revealed a dilated aortic root (50 mm), preserved myocardial contractility, and an ejection fraction of 55%. A significant leak from the aorta into the right atrium was identified (Figure. 1). Computed tomography confirmed contrast leakage from the noncoronary sinus into the right atrium (Figure. 2). An anatomical anomaly was also observed, with the right coronary artery originating just above the ostium of the left coronary artery. Coronary angiography showed no significant stenoses. 

Due to the patient’s deteriorating condition, urgent surgical intervention was performed. A noncoronary sinusoplasty using a bovine pericardial patch was carried out, and the aortic fistula was closed from the right atrial side (Figure. 3). To prevent hematoma formation between the two layers, a TachoSil® hemostatic patch was placed between the native aortic wall and the patch, achieving a satisfactory result. 

The patient was extubated on the first postoperative day. Gradual resolution of peripheral edema and dyspnea was observed, with a weight loss of 10 kg during hospitalization. Postoperative echocardiography and CT angiography confirmed a successful repair (Figure. 4 and 5). The patient was discharged from the Cardiac Surgery Department on postoperative day 14. 

Figure 1: Echocardiographic image before surgery. The arrow indicates the site of the aneurysm rupture into the right atrium.

Figure 2: Contrast-enhanced computed tomography scan performed before surgery. The arrow indicates the site of the aneurysm rupture into the right atrium.

Figure 3: Intraoperative image. The arrow points to the biological patch sewn into the anterior sinus of Valsalva. The hemostatic patch was implanted to connect the two layers.

Figure 4: Postoperative echocardiographic image. The arrow points to the site of patch insertion into the sinus of Valsalva.

Figure 5: Contrast-enhanced computed tomography scan performed after surgery. The arrow points to the site where the patch was sewn into the sinus of Valsalva.

Aneurysms of the sinus of Valsalva may be caused by both congenital abnormalities of the aortic wall structure and acquired factors such as infective endocarditis, atherosclerosis and syphilis [5]. They are frequently associated with other anomalies, most commonly ventricular septal defects and aortic valve insufficiency [6]. The severity of clinical symptoms correlates with the size of the shunt, although asymptomatic cases have also been reported [7]. Surgical repair of a ruptured sinus of Valsalva aneurysm results in a 15-year survival rate of approximately 90% [8]. This case represents an exceptional example of a rapidly developing left-to-right shunt leading to acute heart failure in an elderly patient undergoing cancer immunotherapy. Standard aortic root replacement techniques, such as the Bentall de Bono or David procedure, posed a prohibitively high surgical risk. Therefore, sinusoplasty was chosen as a less invasive yet effective alternative. This case underscores the importance of timely collaboration between cardiologists and cardiac surgeons to ensure rapid diagnosis and surgical management before the onset of multi-organ failure in patients who may initially appear clinically stable.