Aortic sinus aneurysm is a rare disease that belongs to the aortic root disorder in the classification of precordial diseases, Sawers et al. reported an average survival of 3.9 years for patients with ruptured aortic sinus aneurysms without surgical treatment, first described by Hope in 1939, with a prevalence of 0.14-0.23% in Westerners and 0.46-3.5% in Easterners. Etiology: Embryonic impairment of the connection between the middle elastic fibers of the aortic root (distal bulbous septum) and the aortic annulus, resulting in localized areas of weakness in the canal wall, as well as developmental defects of the aortic annulus itself or dysplasia of the muscle tissue outside the wall of the cushion sinus, such as combined pulmonary trunk subventricular septal defects. Degenerative changes in the middle aortic tissue caused by other acquired causes such as syphilis, infection, atherosclerosis, or cystic middle layer necrosis can also trigger aortic sinus aneurysms. Origin from the right coronary sinus is the most common (65%-85%), less frequently from the non-coronary sinus (10%-30%), and least commonly from the left coronary sinus (5%). Sinus aneurysm rupture: Due to high intra-aortic pressure, the sinus wall becomes progressively thinner and expands outward to form a pouch-like protrusion (sinus aneurysm) that protrudes into the adjacent heart chambers. The main triggers for rupture are rapid increases in intra-aortic pressure, such as strenuous activity, emotional stress, infection (SBE), trauma, and medical causes such as cardiac catheterization. Right coronary sinus aneurysms can easily rupture into the right ventricular outflow tract, often combined with VSD and aortic valve prolapse, or into the right atrium; non-coronary sinus aneurysms can easily rupture into the right atrium, rarely into the right ventricle, and rarely into the pericardial cavity; left coronary sinus aneurysms can rupture into the left atrium or left ventricle, and occasionally into the pulmonary artery or pericardial cavity. Combined malformations: ventricular septal defect (VSD), with a higher incidence of VSD in combination with right coronary sinus aneurysm; aortic valve malformation and aortic valve insufficiency; pulmonary artery stenosis, etc. Pathological changes: rupture into the right low-pressure heart cavity, a large amount of left-to-right shunt, increased blood volume in the pulmonary circulation, increased load on the right ventricle, resulting in right ventricular enlargement, pulmonary hypertension and right heart failure; rupture into the right atrial cavity, resulting in a significant increase in right atrial pressure, significant enlargement of the right atrium, obstruction of blood return from the superior and inferior vena cava, and symptoms of right heart failure; rupture into the pericardial cavity, resulting in acute cardiac tamponade and death. Diagnosis: Unruptured sinus tumors may be asymptomatic, but as the sinus tumor increases in size, right ventricular outflow tract obstruction, coronary artery compression, atrioventricular block, supraventricular arrhythmia, or sudden death may occur. The symptoms of ruptured sinus tumor are obvious, starting rapidly with severe pain in the precordial region or epigastrium, chest tightness and dyspnea, a condition similar to angina pectoris (induced by strenuous activity), acute left heart insufficiency symptoms such as palpitations, chest pain, dyspnea and cough, and right heart failure manifestations such as pleural fluid, ascites and lower limb edema in the late stage. Physical examination revealed an increase in pulse pressure difference, the presence of a watery pulse, capillary pulsation and femoral artery gunshot sound, and a palpable tremor between the 3rd and 4th ribs at the left edge of the sternum, where a typical continuous rough murmur could be heard. The main diagnostic basis is echocardiography. Before sinus aneurysm rupture, the corresponding sinus body can be seen enlarged with saccular expansion; after aneurysm rupture, a fissure can be seen and Doppler can show blood shunt through the fissure. Ascending aorta angiography: It can clarify the site of aortic sinus aneurysm rupture and the chamber of the heart into which it has broken. Timing of surgery: Anyone diagnosed with aortic sinus aneurysm should undergo aortic sinus aneurysm resection, regardless of whether it ruptures. Unruptured aortic sinus aneurysms that are combined with other intracardiac malformations requiring surgical correction or are symptomatic (right ventricular outflow tract obstruction, infection, malignant arrhythmia, acute coronary artery opening obstruction) should be operated on as soon as possible. Once ruptured, aortic sinus aneurysms have a significant impact on cardiac function and a poor prognosis, with massive intracavitary shunts, aortic valve annulus enlargement leading to aortic valve insufficiency, and secondary coronary insufficiency, resulting in acute or progressive cardiac insufficiency. Patients with heart failure can be treated with short-term conservative medical therapy, and cardiac function can be adjusted to the best state in the near future to improve the success rate of surgery and shorten the postoperative recovery time, but special attention should be paid to the fact that the timing of surgery should not be delayed in order to improve cardiac function, and only timely correction of hemodynamic disorders caused by sinus aneurysm rupture can effectively relieve cardiac function damage. For individuals with severe hemodynamic impairment, especially combined with moderate to severe aortic valve insufficiency and poor response to drug therapy, surgery should be performed promptly. Heart failure is not a contraindication to surgery. Surgical approach: Currently, a combined incision (aortic and sinus aneurysm breaking into the heart cavity) is advocated to explore the aortic valve, which can be directly perfused through the aortic root incision to obtain good myocardial protection, and sinus aneurysm repair does facilitate the detection and correction of combined malformations, and is not easy to damage the aortic valve and coronary artery opening. Aortic sinus aneurysms <5 mm can be sutured directly, while aneurysms >5 mm should be repaired with a Dacron piece. In case of combined subdural ventricular septal defect, the patch should be used to repair the ventricular defect tightly while spanning and covering the sinus aneurysm fistula to restore the support of the septum to the aortic valve and improve its closing function. Currently, the “one-piece repair” method is used. In patients with mild aortic valve insufficiency (if there is only right coronary valve prolapse and mild regurgitation, the prolapsed leaflet can be reset after patch repair of the sinus aneurysm and VSD), no special treatment is required; in patients with moderate aortic valve insufficiency, folding suspensionplasty (AVP) is used; in patients with severe aortic valve insufficiency, significant malformation, or failure of the valve, aortic valve replacement (AVR) is performed. AVR can block the left ventricular remodeling caused by mechanical stimulation injury, but the ventricular remodeling caused by long-term chronic activation of the neuroendocrine cytokine system needs to be corrected by long-term postoperative drug therapy. Therefore, in patients with combined severe aortic valve insufficiency, in addition to early surgery, long-term close follow-up and anti-heart failure therapy (especially within 1 year after surgery) should be implemented after surgery. The long-term outcome is good, with a 10-year survival rate of more than 90%. Treatment of aortic sinus aneurysms is currently based on surgical methods. In recent years, transcatheter sealing of aortic sinus aneurysm rupture has also been reported. Because of the large number of important tissues adjacent to the aortic sinus and the close proximity to the aortic valve and coronary artery opening, interventional treatment is prone to serious complications. In principle, we do not recommend the use of interventional therapy for this disease. Only patients with small sinus aneurysms that are distant from the aortic valve annulus and coronary artery openings, and who do not have other combined cardiac anomalies, may attempt it.