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Year : 2020  |  Volume : 4  |  Issue : 1  |  Page : 49-52

A Rare Case of Coexisting Subaortic and Submitral Left Ventricular Aneurysms

MAX Diagnostics, Cuttack, Odisha, India

Date of Submission18-Aug-2019
Date of Decision03-Nov-2019
Date of Acceptance24-Nov-2019
Date of Web Publication11-Apr-2020

Correspondence Address:
Dr. Biswaranjan Mishra
201, Chandralok Apartment, Professorpada, Cuttack - 753 003, Odisha
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jiae.jiae_43_19

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Subvalvar left ventricular aneurysm is a rare disorder. Commonly it occurs below the posterior annulus of the mitral valve. Rarely the aneurysm may be found below the aortic annulus. Coexistence of both aortic and submitral aneurysms is still rarer. Here is a 58-year-male who presented with heart failure. Echo revealed an aneurysm below the aortic annulus adjacent to right coronary cusp collapsing in diastole and enlarging in systole. Doppler interrogation showed flow into and out of aneurysm from left ventricle and mild aortic regurgitation. In addition there was a submitral aneurysm below the posterior mitral leaflet with a single localised neck and mild mitral regurgitation. There was evidence of moderate left ventricular systolic dysfunction and grade II diastolic dysfunction with features of right heart failure. He was given diuretics and referred for surgery.

Keywords: Left ventricular aneurysm, subaortic aneurysm, submitral aneurysm

How to cite this article:
Mishra B. A Rare Case of Coexisting Subaortic and Submitral Left Ventricular Aneurysms. J Indian Acad Echocardiogr Cardiovasc Imaging 2020;4:49-52

How to cite this URL:
Mishra B. A Rare Case of Coexisting Subaortic and Submitral Left Ventricular Aneurysms. J Indian Acad Echocardiogr Cardiovasc Imaging [serial online] 2020 [cited 2020 Sep 21];4:49-52. Available from: http://www.jiaecho.org/text.asp?2020/4/1/49/282205

  Introduction Top

Subvalvar or subannular aneurysms are well-known but rare entities found in the left ventricle (LV). The incidence is approximately <1% of all isolated mitral valve diseases.[1] These are predominantly seen in young adults. The first description of such an entity can be traced back to 1812 by Corvisart.[2] Earlier case report was limited to African blacks, but recently, many cases have been reported from different parts of the globe including India.[3],[4] Commonly aneurysms occur in the submitral region below the posterior annulus of the mitral valve. Subaortic aneurysms are relatively rare which occur below the left coronary cusp of the aortic valve. The presence of both submitral and subaortic aneurysms together in one individual is still rarer.

An unusual case of case of subaortic and submitral aneurysm in a 58-year-old individual who presented with congestive heart failure is discussed.

  Clinical Presentation Top

A 58-year-old male presented with progressive dyspnea from New York Heart Association Class I to II over the past 1 year. He was nonhypertensive and nondiabetic and did not have history of angina. Clinical examination revealed raised jugular venous pressure, cardiac enlargement with LV type of apex, and a Grade III/VI pansystolic murmur at the apex and a short early diastolic murmur at the left sternal border. Electrocardiogram showed borderline left ventricular hypertrophy and nonspecific ST/T changes, chest X-ray showed cardiomegaly, LV apex, and signs of pulmonary venous hypertension.

Echo revealed an aneurysmal structure below the aortic annulus adjacent to the right coronary cusp measuring about 1.5 cm × 3.7 cm in apical five-chamber view [Figure 1] and Video Clip 1]. The wall of the aneurysm which was thinner than the LV wall collapsed in diastole and enlarged in systole which was more apparent in parasternal long axis [Figure 2]a and [Figure 2]b and Video Clip 2]. It communicated to LV by a narrow opening with color flow into and out of the aneurysm in systole and diastole, respectively [Video Clip 3] with a continuous-wave Doppler flow pattern shown in [Figure 3]. The low-velocity flow in systole and diastole suggested that it communicated with LV, ruling out communication with aortic root such as  Aneurysm of sinus of Valsalva More Details and aortico-LV tunnel which would have behaved like that of aortic regurgitation (AR). Doppler interrogation of the aortic valve revealed mild AR [Figure 4] and Video Clip 4].
Figure 1: Subaortic aneurysm in apical five-chamber view (arrow) measuring 1.52 cm × 3.76 cm below the right coronary cusp, relatively thin walled and has a narrow opening to Left ventricle. LV: Left ventricle, Ao: Aorta

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Figure 2: (a) Parasternal long axis showing subaortic aneurysm (arrow) with a thin wall which collapses in diastole. (b) Colour Doppler interrogation shows flow in and out of the aneurysm to left ventricle through a narrow opening. LV: Left ventricle, Ao: Aorta, LA: Left atrium

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Figure 3: Continuous-wave Doppler flow pattern to and fro between left ventricle and subaortic aneurysm. The systolic-diastolic flow pattern rules out communication with aortic root, thereby excluding sinus of valsalva aneurysm and aorto-left ventricle tunnel

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Figure 4: Parasternal long axis view showing a jet of aortic regurgitation which is 28% of left ventricular outflow tract

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Apical four-chamber view also revealed a submitral aneurysm below the posterior mitral leaflet measuring 1.5 cm × 2.0 cm [Figure 5] and Video Clip 5]. The submitral aneurysm had a single localized neck which can be classified as type I according to Henning et al.[5] Mitral valve examination by color Doppler showed mild mitral regurgitation [Figure 6] and Video Clip 6].
Figure 5: Submitral aneurysm (arrow) below the posterior leaflet, measuring approximately 15 mm × 20 mm. LV: Left ventricle, LA: Left atrium

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Figure 6: Parasternal long axis view showing an eccentric jet of mild mitral regurgitation. LV: Left ventricle, Ao: Aorta, LA: Left atrium

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Ejection fraction as calculated by the biplane Simpson method [Figure 7] was 39% indicating moderate LV systolic dysfunction. Mitral inflow Doppler interrogation showed deceleration time 175 ms, E/A 0.76, and E/e' 11.13 [Figure 8]. E/e' was derived from the e' velocity of the medial annulus because value from lateral annulus will be erroneous in presence of the aneurysm. The E/e' indicated a grade II diastolic dysfunction. Tricuspid valve interrogation revealed significant tricuspid regurgitation (TR), the peak TR gradient was 59.13 mmHg [Figure 9], and the inferior vena cava was dilated (20 mm) with <50% inspiratory collapse indicating right heart involvement [Figure 10].
Figure 7: End-systolic four-chamber view, calculated ejection fraction by biplane Simpsones rule is 39%

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Figure 8: Pulsed wave mitral inflow showing E/A 0.76, deceleration time 175 m s and E/e' 11.13

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Figure 9: Peak tricuspid regurgitant velocity of 3.84 m/s and a gradient of 59.13 mmHg indicating presence of pulmonary hypertension

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Figure 10: Subcostal view showing dilated inferior vena cava (20 mm) with <50% inspiratory collapse

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  Discussion Top

Head et al. reviewed about 100 cases of subannular LV aneurysms. Twenty-two of them were subaortic aneurysms occurring in young adults. In only two cases, both subaortic and sub mitral aneurysms coexisted. Aneurysms consist of fibrous tissue and lack myocardial fiber; they are contiguous with aortic annulus on the ventricular side of the valve. Subaortic aneurysms are generally smaller compared to submitral aneurysms and have single small orifices between the left coronary cusp and the anterior mitral leaflet. Subaortic aneurysm also occur below other coronary cusps but uncommonly.[6]

Various etiologies are attributed to subannular aneurysms such as inflammatory, traumatic, tubercular, and rheumatic causes, but current understanding is that it is a result of congenital weakness of the fibro-annular tissue of the LV. An association of aneurysm of sinus of Valsalva have also been reported.[7] Aneurysm formation leads to loss of support to the adjacent valve causing regurgitation of the respective valves, which is the usual cause of presentation. Occasionally, the presentation may be due to compression of adjacent structures, rupture of the aneurysm, arrhythmia, and sudden cardiac death.[8]

  Conclusion Top

This case presented with congestive heart failure. LV is burdened with two aneurysms and two regurgitations albeit mild. The combined effect of these lesions slowly took its toll leading to LV dysfunction, pulmonary hypertension and gradually led to right heart failure relatively late at the age of 58 years.

Management is essentially surgical, as the patient was in right heart failure; he was given diuretics and referred for early surgery. Aneurysm resection with corresponding valve repair/replacement is the common surgical method, but the type of surgery depends on the location, size and neck of the aneurysm, status of adjacent valve including the annulus, its relation to coronary artery and complications such as thromboembolism and arrhythmia. It may require further imaging with computerized tomography/magnetic resonance imaging and additional procedure for treatment of arrhythmia including anticoagulation.[8]

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

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Conflicts of interest

There are no conflicts of interest.

  References Top

Antunes MJ. Submitral left ventricular aneurysms. Correction by a new transatrial approach. J Thorac Cardiovasc Surg 1987;94:241-5.  Back to cited text no. 1
Chesler E, Mitha AS, Edwards JE. Congenital aneurysms adjacent to the anuli of the aortic and/or mitral valves. Chest 1982;82:334-7.  Back to cited text no. 2
Ribeiro PJ, Mendes RG, Vicente WV, Menardi AC, Evora PR. Submitral left ventricular aneurysm. Case report and review of published Brazilian cases. Arq Bras Cardiol 2001;76:395-402.  Back to cited text no. 3
Chockalingam A, Gnanavelu G, Alagesan R, Subramaniam T. Congenital submitral aneurysm and sinus of valsalva aneurysm. Echocardiography 2004;21:325-8.  Back to cited text no. 4
Henning JD, Ulrich OV, Hewitson J, Lawrenson J, Davies J. Institutional review – Valves, left ventricular sub-valvar mitral aneurysms. Interact Cardiovasc Thorac Surg 2003;2:547-51.  Back to cited text no. 5
Head HD, Jue KL, Askren CC. Aortic subannular ventricular aneurysms. Ann Thorac Surg 1993;55:1268-72.  Back to cited text no. 6
Baban K, Santhosh S, Raja S. Submitral aneurysm in adults: A rare entity with varied presentations. IHJ Cardiovas Case Rep 2018;2:119-22.  Back to cited text no. 7
Ohlow MA. Congenital left ventricular aneurysms and diverticula: Definition, pathophysiology, clinical relevance and treatment. Cardiology 2006;106:63-72.  Back to cited text no. 8


  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9], [Figure 10]


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