Which statements about treatment for sinus of Valsalva aneurysms are correct?

A. Close observation is appropriate for patients who have an asymptomatic sinus of Valsalva aneurysm without rupture.

B. Patients with sinus of Valsalva aneurysms that rupture should undergo operative repair because progressive heart failure may well lead to death.

D. The best operative approach for closure of a ruptured sinus of Valsalva aneurysm is a dual approach through the aorta and the chamber of entry of the fistula.

E. When a sinus of Valsalva aneurysm ruptures into the pericardium, emergency operation is required.

DISCUSSION: When a found intact sinus of Valsalva aneurysm is asymptomatic, the patient should be followed closely for symptoms but does not usually require operative intervention without symptoms or rupture. A ruptured sinus of Valsalva aneurysm should be repaired by surgical intervention because the significant left-to-right shunt that occurs often leads to progressive heart failure and death. While it is true that cardiac catheterization was the gold standard, the accuracy of noninvasive transesophageal color-flow Doppler echocardiography has replaced it in some cases recently. Operative intervention is not emergent unless the aneurysm ruptures into the pericardial space. If this occurs, symptoms of cardiac tamponade are present and emergent operation is required. Finally, the best operative approach is a dual approach via the aorta and the chamber of entry of the fistula. The major advantage of this approach is that the fistula can be identified through the aorta into the chamber involved and closed securely from both sides. The aortic valve can be protected or replaced as necessary, and the ventricular septum can be inspected for a ventricular septal defect.