Masquerading Associations and Disguised Clinical Presentations of Ruptured Sinus of Valsalva Unveiled by Echocardiography

Sinus of Valsalva aneurysm is a rare cardiac condition with congenital forms due to deficiency in aortic media or acquired as a result of trauma, infective endocarditis, syphilis, and Marfan’s or Behcet’s disease. Congenital type may be associated with a ventricular septal defect or a bicuspid aortic valve. It can have varied clinical presentations, frequently being asymptomatic or insidious symptoms or acute heart failure, depending on acuity of rupture, receiving chamber, and amount of blood flow. Ruptured sinus of Valsalva (RSOV) can open into adjacent cardiac structures, most commonly into the right ventricle, right atrium, right ventricular outflow tract or, less commonly, into the pulmonary artery, left ventricle, left atrium, or pericardial space. Urgent management is essential for symptomatic patients with a ruptured aneurysm. Surgical closure of the defect with a patch has been the conventional treatment, with transcatheter device closure now being commonly used as a feasible, effective, and safe alternative. We present the four cases of RSOV with varied presentations and unique associations.