Heart India

CASE REPORT
Year
: 2015  |  Volume : 3  |  Issue : 3  |  Page : 84--86

Three-Dimensional Transthoracic Echocardiograpic Assessment of Pseudoaneurysm of Mitral Aortic Intervalvular Fibrosa: The Benefit of the Added Dimension


Varun Shankar Narain, Rajiv Bharat Kharwar, Rishi Sethi, Akshyaya Pradhan 
 Department of Cardiology, King Georges' Medical University, Lucknow, Uttar Pradesh, India

Correspondence Address:
Dr. Rajiv Bharat Kharwar
Department of Cardiology, King Georges«SQ» Medical University, Chowk, Lucknow - 226 003, Uttar Pradesh
India

Abstract

We report a case of 25-year-old female presenting to our department for evaluation of dyspnea on exertion. Two-dimensional transthoracic echocardiography showed a sac-like aneurysmal structure arising from the left ventricular outflow tract region protruding into left atrium. Three-dimensional transthoracic echocardiography clearly delineated the origin of the aneurysm from the region of mitral aortic intervalvular fibrosa, helping in confirmation of the diagnosis.



How to cite this article:
Narain VS, Kharwar RB, Sethi R, Pradhan A. Three-Dimensional Transthoracic Echocardiograpic Assessment of Pseudoaneurysm of Mitral Aortic Intervalvular Fibrosa: The Benefit of the Added Dimension.Heart India 2015;3:84-86


How to cite this URL:
Narain VS, Kharwar RB, Sethi R, Pradhan A. Three-Dimensional Transthoracic Echocardiograpic Assessment of Pseudoaneurysm of Mitral Aortic Intervalvular Fibrosa: The Benefit of the Added Dimension. Heart India [serial online] 2015 [cited 2020 Sep 23 ];3:84-86
Available from: http://www.heartindia.net/text.asp?2015/3/3/84/157281


Full Text

 BACKGROUND



Pseudoaneurysm of mitral aortic intervalvular fibrosa (PMAIVF) is a false aneurysm arising in the fibrous and relatively avascular junction between the left half of the non-coronary cusp and the adjacent third of the left coronary cusp of the aortic valve and the anterior mitral leaflet. Although most cases of PMAIVF have been described as a complication of aortic valve infective endocarditis, aortic valve surgery or chest trauma, [1] rare cases where no obvious cause was evident have also been reported. [2] Two-dimensional (2D) transthoracic echocardiography (TTE) and transesophageal echocardiography (TEE) have been the cornerstone for non-invasive imaging of PMAIVF. We report a case where three-dimensional transthoracic echocardiography (3D TTE) clearly delineated the exact site of origin, the neck, the body and the anatomical relationship of the pseudoaneurysm that helped us in confirming the diagnosis of this rare condition.

 Case Report



A 25-year-old female was referred to our department with complaints of dyspnea on effort for last 6 months and a suspicious aneurysmal structure in left atrium on 2D TTE done outside. There was no history of fever, chest wall trauma, aortic or mitral valve endocarditis or any surgery near aortic valve region. Her clinical examination showed an irregularly irregular pulse, blood pressure 120/70 mmHg and a pansystolic murmur at the apex. Electrocardiogram showed atrial fibrillation and chest X ray was significant for cardiomegaly. 2D TTE [[Figure 1], Videos 1 and 2] showed a aneurysmal sac-like structure originating from the left ventricular out flow tract region protruding into left atrium. Color Doppler examination [Figure 2] showed the presence of severe eccentric valvular mitral regurgitation (MR) leading to dilatation of left ventricle and left atrium. The mechanism for MR seems to be incomplete coaptation of the anterior mitral leaflets due to the aneurysmal sac impinging on it. The aortic valve was tricuspid with no evidence of infective endocarditis [Figure 4] and the left ventricular ejection fraction was preserved. The aneurysmal structure was expanding in systole and collapsing in diastole and so a strong possibility of PMAIVF was considered. The patient did not give consent for TEE evaluation and so 3D TTE examination was carried using Vivid 7 dimension, GE medical system. 3D TTE [[Figure 3], Videos 3 and 4] clearly outlined the opening, the neck and the body of the pseudoaneurysm, its motion during the cardiac cycle as well as its anatomical relationship with the surrounding structures, which helped in confirmation of the diagnosis of PMAIVF. The patient was referred for possible corrective surgery in order to prevent the future complications.{Figure 1}{Figure 2}{Figure 3}{Figure 4}

 DISCUSSION



The MAIVF is a junctional structure between the aortic and the mitral valves where the left half of the non-coronary cusp and the adjacent third of the left coronary cusp becomes continuous with the anterior mitral leaflet. [3] Its relative avascular nature makes it susceptible to infection and injury resulting into pseudoaneurysm formation. Aortic valve endocarditis, aortic valve surgery and chest trauma are the leading causes of PMAIVF although none was present in our case. [1] Unruptured PMAIVF may compress the adjacent coronary artery leading to symptomatic coronary artery obstruction or thrombus may form within its cavity leading to systemic embolization and stroke. [4] Rupture of the PMAIVF may occur into left atrium, left ventricular outflow region, ascending aorta or the pericardium leading to catastrophic outcomes.

Non-invasive imaging with echocardiography is the first choice for evaluation of PMAIVF with TTE and TEE having a sensitivity rates of 43% and 90%, respectively. [5] Real-time 3D TTE has emerged as a valuable tool for non-invasive assessment of various disorders owing to its potential for better delineation of anatomical relationship between the various cardiac structures and depicting the depth of the structure by cropping the data in various imaging planes. [6] Real-time 3D echocardiography has proved useful in delineation of PMAIVF in recent reports of Han, et al. and Selcuk, et al. [7],[8] In our case, 2D TTE was highly suspicious for PMAIVF, but as the patient did not give consent for TEE, 3D TTE was carried out and the diagnosis was confirmed.

 CONCLUSION



Because of the potential life-threatening complication of rupture of PMAIVF, early diagnosis is crucial for proper planning of the treatment. Although 2D TTE and TEE remain the cornerstone for the diagnosis of PMAIVF, our case demonstrates how 3D TTE can be an invaluable tool for confirmation of the diagnosis.

References

1Espinosa-Caliani JS, Montijano A, Melero JM, Montiel A. Pseudoaneurysm in the mitral-aortic intervalvular fibrosa. A cause of mitral regurgitation. Eur J Cardiothorac Surg 2000;17:757-9.
2Bolcal C, Baysan O, Doganci S, Uzun M, Demirkilic U, Tatar H. A mitral-aortic intervalvular fibrosa false aneurysm in a patient without overt heart disease. Can J Cardiol 2007;23:389-90.
3Chesler 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.
4Daniel WG, Mügge A, Martin RP, Lindert O, Hausmann D, Nonnast-Daniel B, et al. Improvement in the diagnosis of abscesses associated with endocarditis by transesophageal echocardiography. N Engl J Med 1991;324:795-800.
5Afridi I, Apostolidou MA, Saad RM, Zoghbi WA. Pseudoaneurysms of the mitral-aortic intervalvular fibrosa: Dynamic characterization using transesophageal echocardiographic and Doppler techniques. J Am Coll Cardiol 1995;25:137-45.
6Le Tourneau T, Polge AS, Gautier C, Deklunder G. Three-dimensional echography: Cardiovascular applications. J Radiol 2006;87:1993-2004.
7Han J, He Y, Li Z, Chen J, Gu X, Pei J, et al. Pseudoaneurysm of the mitral-aortic intervalvular fibrosa in a patient after radio frequency catheter ablation of atrial fibrillation. J Ultrasound Med 2009;28:249-51.
8Selçuk H, Selçuk MT, Tüfekçioğlu O, Arat N. The use of three-dimensional echocardiography in the visualization of pseudoaneurysm of the mitral-aortic intervalvular fibrosa. Turk Kardiyol Dern Ars 2009;37:328-31.