A Valsalva aneurysm is a rare and serious heart condition involving an abnormal bulge or swelling in the aorta, the body’s largest artery. This condition is specifically located in one of the three small pouches, known as the sinuses of Valsalva, which sit directly above the aortic valve. While often present from birth, it can sometimes develop later in life. If left unaddressed, a Valsalva aneurysm can lead to severe complications, including heart failure.
Understanding Valsalva Aneurysm
A Valsalva aneurysm originates from a weakened area in the aortic wall, specifically within one of the three sinuses of Valsalva, which are dilations in the aortic root just above the aortic valve. This weakness often stems from a defect in the elastic tissue at the junction where the aortic wall meets the heart’s fibrous ring. The aneurysm typically forms as a thin-walled swelling that can enlarge over time.
This condition is named after Antonio Valsalva, who first described these anatomical pouches. The aneurysm may rupture into an adjacent heart chamber, most commonly the right ventricle (60-90% of cases) or the right atrium (10% of cases), creating an abnormal connection or “shunt” between the aorta and the heart. Rupture into the left heart chambers, pericardium, pulmonary artery, or superior vena cava is less common.
Valsalva aneurysms are usually congenital, meaning they are present at birth. These congenital cases are frequently associated with other heart defects, such as a ventricular septal defect (a hole between the heart’s lower chambers) or a bicuspid aortic valve. A Valsalva aneurysm can also be acquired later in life due to factors like chest trauma, infections such as endocarditis or syphilis, or connective tissue disorders like Marfan syndrome. Degenerative changes in the aortic wall from aging or atherosclerosis can also contribute to acquired forms.
Recognizing the Signs
A Valsalva aneurysm often remains undetected until symptoms appear, which commonly occurs if the aneurysm ruptures. Unruptured aneurysms may cause no symptoms, but if large enough, they can compress nearby structures, leading to abnormal heart rhythms or obstruction of blood flow. A blood clot can form within the aneurysm, possibly leading to a stroke or heart attack if it blocks a coronary artery.
When a Valsalva aneurysm ruptures, symptoms appear suddenly and can include acute chest pain or pain in the upper right abdomen. Shortness of breath is a common symptom, which can progress to difficulty breathing even at rest. Patients might also experience fatigue, heart palpitations, or a continuous heart murmur.
The severity of symptoms after rupture depends on the size of the abnormal connection and the specific heart chamber into which the aneurysm ruptures. If the rupture leads to significant blood shunting from the aorta into a lower-pressure heart chamber, it can lead to signs of heart failure, including progressive cough, swelling, and reduced urine output. In severe cases, a rupture into the pericardial space (the sac surrounding the heart) can cause cardiac tamponade, a life-threatening condition where blood compresses the heart and prevents it from filling properly.
Diagnosis and Confirmation
The initial step in diagnosing a Valsalva aneurysm involves an echocardiogram, which uses sound waves to create images of the heart. A transthoracic echocardiogram (TTE), performed by placing a probe on the chest, can detect these aneurysms and may reveal a characteristic “windsock deformity” if the aneurysm has ruptured. Color-flow Doppler imaging is useful for identifying a ruptured aneurysm by showing abnormal blood flow.
For more detailed imaging or when planning treatment, a transesophageal echocardiogram (TEE) may be used. This procedure involves a probe inserted into the esophagus, providing clearer images of the aneurysm and surrounding heart structures. Cardiac magnetic resonance imaging (MRI) and electrocardiography (ECG)-gated computed tomographic angiography (CTA) are common diagnostic tools. Cardiac MRI offers excellent soft tissue contrast and can provide information about blood flow, while CTA provides high-resolution, three-dimensional images of the aortic root, helpful for surgical planning. Cardiac catheterization or retrograde thoracic aortography may also be performed to confirm the diagnosis or assess the hemodynamic impact.
Treatment Options
Treatment for a Valsalva aneurysm focuses on repairing the defect and preventing serious complications. While medical management can help stabilize symptoms, surgical repair remains the standard of care for most cases, particularly if the aneurysm has ruptured. Urgent surgical intervention is recommended for all ruptured aneurysms causing blood to shunt between heart chambers, due to the potential for rapid clinical deterioration.
Open-heart surgery is a common approach, where the aneurysmal sac is removed and the defect is repaired, either by direct suturing or by using a patch closure. This surgical method also allows for the repair of any associated heart defects, such as a ventricular septal defect or aortic valve regurgitation, during the same procedure. Long-term outcomes following surgical repair are favorable, with a reported 10-year survival rate of 90% after repair of a ruptured aneurysm.
A less invasive option, transcatheter closure, is increasingly used in suitable cases. This procedure involves guiding a wire and a device through blood vessels from the groin to close the aneurysm, avoiding the need for a large incision. The goal of both surgical and catheter-based interventions is to close the rupture and prevent further complications like heart failure. Close monitoring and follow-up care are important after treatment to ensure proper healing and to detect any potential recurrences or new issues.