Background Because not much is known about the long-term results of surgical treatment of ruptured sinus of Valsalva aneurysm (RSVA), we reviewed our entire 37-year experience with this condition.Methods and Results From August 1956 through September 1993, 31 patients aged 3 to 54 years (median age, 29 years) underwent surgical correction of RSVA.Aneurysms originated in the right (n=24) and noncoronary (n=7) sinuses and entered the right ventricle in 21 patients and the right atrium in 10. Coexistent cardiac lesions included ventricular septal defect (VSD) (n=16, 15 of which were subarterial) and aortic valve insufficiency (n=13). There was a highly significant correlation between aortic insufficiency and the presence of an associated subarterial VSD (P<.0001). There was no hospital mortality. One patient (3.2%) died of endocarditis 9 years after subsequent aortic valve replacement; overall survival was 95% at 20 years. Two foreign patients were lost to follow-up after 11 and 13 years, respectively. Follow-up in the remaining 28 survivors extended to 37 years (mean, 25.7 years). Five patients (16.1%) underwent reoperation for aortic valve replacement (n=3), closure of recurrent fistula (n=1), and closure of both recurrent fistula and recurrent VSD (n=1); all had their primary operation before 1976. All patients who had reoperation had right sinus of Valsalva-to-right ventricle fistulas, and 4 had an additional subarterial VSD. Risk of reoperation was higher with right ventricle fistulas than with right atrium fistulas, and this approached statistical significance (P=.06). Risk of reoperation in patients with right ventricle fistulas was lower when an aortotomy (with or without right ventriculotomy) was used during repair (1 of 8, 12.5%) versus right ventriculotomy only (4 of 13, 30.8%), although this did not reach statistical significance (P=.10). Need for reoperation was increased with the presence of a subarterial VSD (P=.08) but not with location of fistula or type of repair (direct suture versus patch). Of 9 patients with mild aortic insufficiency at primary operation, two developed late severe aortic insufficiency necessitating aortic valve replacement at 21 and 31 years, respectively. Twenty-five patients are in New York Heart Association class I, and 3 are in class II.Conclusions Long-term survival after surgical treatment of RSVA is excellent. The risk for recurrent fistula or VSD is minimal in the current era. Late aortic insufficiency is still a risk, especially in right sinus of Valsalva-to-right ventricle fistula with associated subarterial VSD. Repair of RSVA through an aortotomy with or without cardiotomy permits inspection of the aortic root complex and facilitates aortic valve repair; this approach may reduce the incidence of late aortic insufficiency. (Circulation. 1994;90(part 2):II-20-II-29.)