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Background Sinus of Valsalva aneurysm (SVA) is a rare cardiac abnormality occurring in 0.09% of the general population, but few reports have examined its recurrence. Unruptured SVAs are usually asymptomatic. Case summary A 50-year-old woman presented with chest pain and a history of surgery for a ruptured right coronary SVA 32 years prior. Echocardiography showed the recurrence of an unruptured SVA of the non-coronary sinus with moderate aortic regurgitation, severe mitral regurgitation, and severe tricuspid regurgitation. Cardiac computed tomography (CT) revealed compression of the right coronary artery (RCA) between the SVA and sternum. Adenosine triphosphate stress myocardial perfusion imaging (MPI) identified reversible ischaemia of the inferior wall. The patient underwent patch closure of the SVA, aortic valve replacement, mitral valvuloplasty, and tricuspid annuloplasty. Post-operative MPI showed no residual ischaemia, and CT confirmed both successful repair of the SVA and intact RCA. Discussion This case provides two noteworthy findings. First, the SVA recurred after 32 years. Second, a non-coronary SVA causing myocardial ischaemia is extremely rare given the long anatomical distance between the non-coronary sinus and coronary arteries. In our patient, the non-coronary SVA grew large enough within the anterior mediastinum to cause RCA compression.