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

doi:10.4103/2321-449X.157281

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

Date of Web Publication

7-Sep-2015

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

Source of Support: None, Conflict of Interest: None

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DOI: 10.4103/2321-449X.157281

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.

Keywords: Three-dimensional echocardiography, mitral aortic intervalvular fibrosa, pseudoaneurysm

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;3:84-6

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 2021 Jan 17];3:84-6. Available from: https://www.heartindia.net/text.asp?2015/3/3/84/157281

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: Two-dimensional transthoracic echocardiography. Parasternal long-axis view (a and b) and apical four-chamber view (c and d) showing a aneurysmal sac like structure (indicated by *) which was collapsing in diastole and expanding in systole suggestive of pseudoaneurysm originating from the left ventricular outflow tract region most likely mitral aortic intervalvular fibrosa. The LA and LV are dilated. Ao: Aorta, LA: Left atrium, RA: Right atrium

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Figure 2: Two-dimensional transthoracic echocardiography. Apical four-chamber view (a) with color Doppler (b) showing severe valvular mitral regurgitation with an eccentric jet directed laterally because of the pseudoaneurysm (indicated by *) leading to improper coaptation of anterior mitral leaflet. LA: Left atrium, LV: Left ventricle, RA: Right atrium, RV: Right ventricle

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Figure 3: Three-dimensional transthoracic echocardiography. The relationship of the the pseudoaneurysm with the surrounding structures can be clearly delineated (a and b). After cropping and slicing the 3D image, the opening (arrow in c and d) in the region of PMAIVF as well as the neck and the body of the pseudoaneurysm (D) was clearly outlined. LA: Left atrium, LV: Left ventricle, RA: Right atrium. Pseudoaneurysm indicated by (*)

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Figure 4: Two-dimensional echocardiography. Basal short axis view showing the trileaflet nature of the aortic valve without any evidence of infective endocarditis. AV: Aortic valve, LA: Left atrium, RA: Right atrium, RV: Right ventricle

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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

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