Bring a large pot of salted water to a boil. Cook the pasta according to package directions until al dente. Reserve ½ cup of the pasta cooking water, then drain and set the pasta aside.

While the pasta cooks, heat a large skillet over medium-high. Add the sausage, breaking it up with a spoon. Cook until no pink remains and the bits are nicely browned, about 6–8 minutes. Drain off excess fat, leaving a tablespoon for flavor if desired.

Reduce heat to medium. Add the minced garlic to the skillet and cook about 30 seconds until fragrant.

Stir in the chopped canned tomatoes, dried minced onion, tomato paste, and Italian seasoning. Bring to a gentle simmer and cook 3–4 minutes to concentrate flavors.

Pour in the heavy cream and stir. Simmer until the sauce thickens slightly, about 5–7 minutes. If the sauce looks too thick, add a splash of reserved pasta water.

Add the cooked pasta and grated Parmesan to the skillet. Toss to combine and coat the pasta in the sauce. Season with salt and freshly ground black pepper to taste.

Simmer over medium-low just until the cheese melts and everything is heated through, 2–3 minutes. Serve topped with fresh basil or parsley and extra Parmesan.