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   Table of Contents      
CASE REPORT
Year : 2021  |  Volume : 7  |  Issue : 2  |  Page : 168-170

Pseudoaneurysm of Mitral-Aortic Intervalvular Fibrosa – A Case Report


Department of CTVS, SSSIHMS Puttaparthi, Andhra Pradesh, India

Date of Submission11-Feb-2021
Date of Decision18-Apr-2021
Date of Acceptance19-Apr-2021
Date of Web Publication22-Jul-2021

Correspondence Address:
Dr. C.H. Praveen
Junior Consultant, Department of CTVS, Sri Sathya Sai Institute of Higher Medical Sciences, Prasanthigram, Puttaparthi, Anantapur district, Andhra Pradesh, 515134
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/mamcjms.mamcjms_14_21

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  Abstract 


Pseudoaneurysm of mitral-aortic intervalvular fibrosa (P-MAIVF) is a rare, well-known entity with few cases reported in the literature. We here present a case report of repair of large P-MAIVF that was successfully managed. Postoperatively patient had an uneventful course and patient was asymptomatic at 3rd month follow-up. The cause of P-MAIVF could be an atheromatous ulcer at interleaflet trigone with severely calcified aortic valve as in our case. Even if the imaging and diagnostic modalities are inconclusive, a strong suspicion should be made preoperatively in the presence of abovementioned combination for better preparedness to improve the outcome of surgery.

Keywords: Aortic valve replacement (AVR), mitral-aortic intervalvular fibrosa, pseudoaneurysm


How to cite this article:
Praveen C, Chhotu SH, Roy A, Desai NB. Pseudoaneurysm of Mitral-Aortic Intervalvular Fibrosa – A Case Report. MAMC J Med Sci 2021;7:168-70

How to cite this URL:
Praveen C, Chhotu SH, Roy A, Desai NB. Pseudoaneurysm of Mitral-Aortic Intervalvular Fibrosa – A Case Report. MAMC J Med Sci [serial online] 2021 [cited 2021 Dec 6];7:168-70. Available from: https://www.mamcjms.in/text.asp?2021/7/2/168/322143




  Introduction Top


Pseudoaneurysm of mitral-aortic intervalvular fibrosa (P-MAIVF) is a rare entity with very few cases reported in the literature. The first successful repair was published in 1966.[1]


  Case presentation Top


A 57-year-old hypothyroid female came with complaints of dyspnea of exertion in New York heart association functional class III for 3 years. Chest X-Ray [Figure 1] revealed cardiomegaly with cardiothoracic ratio of 78.6%. Electrocardiogram showed normal sinus rhythm (NSR) with left ventricular hypertrophy and intermittent ventricular premature complexes (VPCs). Transthoracic echocardiography (TTE) showed bicuspid aortic valve (AoV) with severe aortic stenosis (AS), dilated ascending aorta, and mild mitral and aortic regurgitation (MR/AR). Gradient across the AoV was 102/80 (peak/mean) mmHg with left ventricular internal dimension (diastolic/systolic) of 5.8 × 4.2 cm and left ventricular ejection fraction (LVEF) 60%. Cardiac cath done for coronary arteries was normal. Noncontrast computerized tomography (NCCT) thorax showed densely calcified AoV with dilated ascending aorta measuring 5.9 × 5.4 cm. It also revealed a new chamber, which was not seen in TTE and cath, measuring 6.0 × 4.5 cm in periaortic area between aorta and superior vena cava (SVC), above the roof of left atrium (LA) appearing to be a part of LA. Patient was taken up for surgery. Intraoperatively transesophageal echocardiography (TEE) did not reveal new chamber. However, after the pericardium was opened, a chamber of 5.0 × 5.0 cm was found between aorta and LA, pressing against SVC-right atrial (RA) junction [Figure 2]. Ascending aorta was opened; AoV was bicuspid and densely calcified. There was a small opening in interleaflet trigone of the LV between noncoronary cusp (NCC) and left coronary cusp (LCC). There was no evidence of vegetation on AoV and anterior mitral leaflet (AML) was normal. The opening was found to communicate with the chamber seen but not with any cardiac structures [Figure 3]. Thus P-MAIVF was diagnosed. AoV was excised and replaced with 25 mm mechanical tilting disc valve (TTK Chitra). Pseudoaneurysm was excised, and the walls appeared ragged, calcific, and fibrosed at places. The opening was closed with pericardial patch placed externally using 4-O prolene. Aortoplasty was done. Off-bypass heart regained NSR spontaneously and TEE showed normal functioning prosthetic AoV, no paravalvular leak or additional shunt, normal mitral and tricuspid valve, LVEF-50%, and normal right ventricular function. Postoperatively, the patient developed frequent VPCs and tachyarrhythmias, which were managed with antiarrhythmic drugs. Her rhythm stabilized to atrial fibrillation with controlled ventricular rate before discharge. At 3rd month postoperative follow-up, she was asymptomatic. P-MAIVF tissue histopathology report revealed irregularly thickened fibrocollagenous tissue with myxoid and hyaline change, ulceration, fibrinoid necrosis, and fatty streak suggestive of “Atheromatous ulcer”.
Figure 1 Chest X-ray

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Figure 2 Pseudoaneurysm between aorta and LA, pressing against SVC-RA junction. LA, left atrium; RA, right atrium; SVC, superior vena cava

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Figure 3 Hole in MAIVF. MAIVF, mitral-aortic intervalvular fibrosa

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  Discussion Top


The mitral-aortic fibrosa is an area in the left ventricular outflow tract where the aortic wall and NCC-LCC of AoV relate to the base of the AML. This structure is in juxtaposition with an epicardial wedge of fat that lies between the posterior wall of the aorta and the LA.[2],[3] Rupture of the mitral-aorta fibrosa results in pseudoaneurysm formation within this pericardial fat. It may rupture into the pericardial sac resulting in a fatal hemopericardium or may rupture into the LA creating a shunt from the left ventricle into the LA via the ruptured aneurysm.[4] In our case, the first suspicion of some abnormality was made on chest X-ray that showed unusual cardiomegaly for a case of severe AS. It was thought to be due to cardiac failure. NCCT thorax showed a large chamber above LA, which was misinterpreted as part of LA. Berrizbeitia and Anderson advocate routine use of ultrafast CT scanning in the diagnosis of valve endocarditis suspected to involve the MAIVF or the aortic annulus. According to them, the combination of ultrafast CT scanning with TEE provides an accurate picture of the relationship of the pseudoaneurysm to adjacent structures and may obviate the need for ventriculography.[5] This patient had a large P-MAIVF that if had ruptured into the pericardial cavity would have been catastrophic.


  Conclusion Top


P-MAIVF is commonly in association with typical triad of bicuspid AoV, severe AS/AR, and infective endocarditis. In the absence of previous aortic surgeries or an evidence of infective endocarditis or trauma, the cause of P-MAIVF could be an atheromatous ulcer at interleaflet trigone with severely calcified AoV, as in our case. Even if the imaging and diagnostic modalities are inconclusive, a strong suspicion should be made preoperatively in the presence of the abovementioned combination for better preparedness to improve the outcome of surgery. Despite having the suspicion of some abnormality because of inappropriate imaging findings, which could not be correlated with clinical symptoms, correct diagnosis preoperatively was not achieved, but cautious analytical approach intraoperatively adopted by us went a long way for a better patient outcome.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Waldhausen JA, Petry EL, Kurlander GJ. Successful repair of subvalvular annular aneurysm of the left ventricle. N Engl J Med 1966;275:984-7.  Back to cited text no. 1
    
2.
Chesler E, Korns ME, Porter GE, Reyes CN, Edwards JE. False aneurysm of the left ventricle secondary to bacterial endocarditis with perforation of the mitral-aortic invervalvular fibrosa. Circulation 1968;37:518-23.  Back to cited text no. 2
    
3.
Salerno D, Donati G, Forconi S, Gori T. Giant pseudoaneurysm of the mitro-aortic intervalvular fibrosa: incidental diagnosis. Intern Emerg Med 2008;3:279-82.  Back to cited text no. 3
    
4.
Meyerowitz C, Jacobs L, Kotler M, Ioli A, Wertheimer J. Four-year follow-up of a pseudoaneurysm of the mitral-aortic fibrosa. Am Heart J 1991;122:589-92.  Back to cited text no. 4
    
5.
Berrizbeitia LD, Anderson WA. Ultrafast computed tomography in infectious pseudoaneurysm of the left ventricular outflow tract. J Thorac Cardiovasc Surg 1997;114:138-9.  Back to cited text no. 5
    


    Figures

  [Figure 1], [Figure 2], [Figure 3]



 

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Abstract
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