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 Table of Contents  
INTERESTING CASE REPORT
Year : 2021  |  Volume : 5  |  Issue : 1  |  Page : 54-57

Unusual Cause of Left Ventricular Pseudoaneurysm


Department of Cardiology, Government Medical College, Thiruvananthapuram, Kerala, India

Date of Submission05-May-2020
Date of Decision26-Jul-2020
Date of Acceptance17-Aug-2020
Date of Web Publication04-Feb-2021

Correspondence Address:
Dr. P Krishnakumar
Associate Professor of Cardiology, Govt Medical College, Trivandrum, Kerala
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jiae.jiae_21_20

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  Abstract 

Closed mitral valvotomy (CMV) became an accepted surgical procedure to open a stenotic mitral valve (MV) about 50 years ago. CMV is performed through an incision in the left atrial appendage. Tubbs dilator is passed in to the left ventricle via the apex and then advanced retrogradely through the stenosed MV and is then opened within the orifice to split the commissures. The dilator is then removed and the orifice closed. Incisional left ventricular pseudo aneurysm has been described as a rare complication of this technique. Here we encountered a similar scenario. Percutaneous transmitral commissurotomy has virtually replaced CMV. But with the expanding use of the transapical approach to treat a variety of structural heart diseases, especially transcutaneous aortic valve replacement, one is likely to encounter similar complications in the modern era also.

Keywords: Closed mitral valvotomy, left ventricular pseudoaneurysm, mitral stenosis


How to cite this article:
Krishnakumar P, Koshy A G, Iype M, Viswanathan S. Unusual Cause of Left Ventricular Pseudoaneurysm. J Indian Acad Echocardiogr Cardiovasc Imaging 2021;5:54-7

How to cite this URL:
Krishnakumar P, Koshy A G, Iype M, Viswanathan S. Unusual Cause of Left Ventricular Pseudoaneurysm. J Indian Acad Echocardiogr Cardiovasc Imaging [serial online] 2021 [cited 2021 Jul 23];5:54-7. Available from: https://www.jiaecho.org/text.asp?2021/5/1/54/308725


  Introduction Top


The treatment of rheumatic mitral stenosis (MS) ranges from conservative medical management to closed mitral valvotomy (CMV) and the more recent balloon mitral valvuloplasty. Improvement of symptoms after CMV was demonstrated many years ago. Refinement in technique and the routine use of metal dilator have produced sustained clinical improvement at low risk. Open mitral valvotomy or MV repair has the advantage of direct visualization of the MV apparatus, understanding the pathology and relieving the obstruction. MV replacement is the only option in severely diseased and calcific valves and in those with significant mitral regurgitation. Restenosis after CMV has been estimated to be 4.2-11.4 per thousand patients per year between the 5th and 15th year of follow-up.[1] CMV used to be a good palliative and cost-effective treatment. Mitral valve orifice area, peak and mean transmitral diastolic gradients, pulmonary artery pressures, and functional status showed remarkable improvement in most patients over a long span of time. The closed approach allows for a substantial reduction in cost compared to recent interventional procedures, making it still an option in resource challenged economies. Here, we report a very rare complication left ventricular pseudo aneurysm (LVPA) of this once frequently performed procedure.


  Clinical Presentation Top


A 43-year-old housewife was admitted with worsening breathlessness and palpitations. She was a known case of rheumatic MS and had undergone a successful closed CMV 16 years prior. She was in the New York Heart Association functional class 1 after the procedure but became symptomatic a few years later. She was found to be in atrial fibrillation and was in heart failure at the time of admission. There was evidence of mitral restenosis with mild mitral regurgitation [Figure 1], [Figure 2], [Figure 3], [Figure 4]. Transthoracic echocardiography revealed moderate to severe MS with a valve area of 1.3 cm2 and a mean transmitral gradient of 14 mmHg. Moderate tricuspid regurgitation could be detected and estimated pulmonary artery pressure was 68 mm Hg. There was thickening and doming of the anterior mitral leaflet and the posterior mitral leaflet had restricted mobility. Both atria were dilated. An echo-free space measuring 50 mm × 32 mm was noted in relation to the apical anterolateral wall of the left ventricle (LV) [Figure 5]. The cavity communicated with the LV through a narrow orifice and the maximum diameter of the neck was 7 mm [Figure 6]. Filling defects suggestive of laminated thrombi could be identified toward the walls of the sac. Color Doppler revealed “to-and-fro” flow at the neck of the cavity, with blood entering the aneurysmal sac during systole [Figure 7]. An LV angiography was deferred because of the possible risk of systemic embolization and rupture.
Figure 1: Parasternal long axis view of transthoracic echocardiography showing mitral restenosis and dilated left atrium

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Figure 2: Parasternal short axis view of transthoracic echocardiography showing fused anterolateral mitral commissure and severe restenosis

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Figure 3: The picture shows diastolic flow through the stenosed mitral valve and diastolic flow in to the left ventricular pseudoaneurysm

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Figure 4: Continuous wave Doppler across mitral valve showing mitral restenosis

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Figure 5: Apical 4 chamber view of transthoracic echocardiography showing left ventricular pseudo aneurysm and the narrow neck

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Figure 6: Apical 4 chamber view with color Doppler showing the narrow neck and systolic filling of the left ventricular pseudo aneurysm

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Figure 7: Pulsed-wave Doppler with sample volume placed at the neck of the left ventricular pseudo aneurysm showing systolic flow

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  Discussion Top


CMV was first performed by Sir Henry Sessions Souttar in 1925. CMV is performed through an incision in the LA appendage. A purse string technique is used to prevent blood loss and air embolism. Tubbs dilator is passed into the LV through the apex and then opened within the orifice of the valve to split the commissures. The index finger introduced through the incision in the LA appendage directs and confirms the tip of the metallic device across the mitral orifice [Figure 8]. The dilator is then removed and the orifice closed. LVPA is a rare complication of CMV with an increased risk of rupture and consequently high mortality.[2] This occurs as a result of the sutures giving way and the hemopericardium is contained by the overlying fibrosis and pericardial adhesions.[3] A communication with the ventricular cavity persists. More common causes of LVPA are myocardial infarction, trauma, and infections. Common locations are the inferior and posterior walls. The diameter of the orifice of the neck is smaller than the diameter of the cavity in the case of pseudoaneurysm. This is in contrast to true aneurysm, where the neck is wider.[4] Surgical closure is the recommended mode of treatment.[5] If untreated, it may result in complete rupture, arrhythmias, thromboembolism and congestive heart failure.[6] However, Sakai et al.[7] in their series of eight patients with LVPA following MV surgery treated seven of them medically without any complications. They opined that when the LVPA is small and the communicating neck of the LVPA is very narrow, conservative management of a patient with LVPA may be possible. Clinical features of LVPA include chest pain, heart failure and systolic and diastolic murmur. Patients can be asymptomatic during the postoperative period. Hence, clinical features are nonspecific and unreliable. Although transthoracic echocardiography is sufficient in most cases, transesophageal echocardiography (TEE) may be required in certain cases. MV and left atrium being posterior structures are better studied by TEE. The differential diagnosis for LVPA includes a localized pericardial effusion or hematoma, pericardial cyst, or a diverticulum. LVPA can be diagnosed by LV angiography, computed tomography or cardiac magnetic resonance imaging.[8] LV angiography is invasive and is not without significant risks such as thromboembolism and rupture.
Figure 8: Tubbs dilator introduced apically across the mitral valve, directed by the index finger introduced through an incision in the left atrial appendage

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We report this case to highlight importance of cardiac imaging for the diagnosis of an unusual complication, several years after a procedure. It is good to consider this rare entity in addition to the usual factors which could contribute to worsening heart failure, arrhythmias, or thromboembolism in a patient with structural heart disease who has undergone a procedure. Early intervention is advised for better outcome. As our patient was unwilling for surgery, she was kept under medical follow-up.

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.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
John S, Bashi VV, Jairaj PS, Muralidharan S, Ravikumar E, Rajarajeswari T, et al. Closed mitral valvotomy: Early results and long-term follow-up of 3724 consecutive patients. Circulation 1983;68:891-6.  Back to cited text no. 1
    
2.
De Vries AG, Saelman JP, Sutherland GR. The value of colour flow mapping in the diagnosis of a combined pseudoaneurysm and large true left ventricular aneurysm. Eur Heart J 1991;12:280-2.  Back to cited text no. 2
    
3.
Konen E, Merchant N, Gutierrez C, Provost Y, Mickleborough L, Paul NS, et al. True versus false left ventricular aneurysm: Differentiation with MR imaging–initial experience. Radiology 2005;236:65-70.  Back to cited text no. 3
    
4.
Aguiar J, Barba Mdel M, Gil JA, Caetano J, Ferreira A, Nobre A, et al. Left ventricular aneurysm and differential diagnosis with pseudoaneurysm. Rev Port Cardiol 2012;31:459-62.  Back to cited text no. 4
    
5.
Mundth ED, Mayer HS, Hopkins FT. Surgical management of post-infarction leaking left ventricular false aneurysm. J Cardiovasc Surg (Torino) 1989;30:796-7.  Back to cited text no. 5
    
6.
Yeo T, Malouf J, Oh J, Seward JB. Clinical profile and outcome in 52 patients with cardiac pseudoaneurysm. Ann Intern Med 1998;128:299-305.  Back to cited text no. 6
    
7.
Sakai K, Nakamura K, Ishizuka N, Nakagawa M, Hosoda S. Echocardiographic findings and clinical features of left ventricular pseudoaneurysm after mitral valve replacement. Am Heart J 1992;124:975-82.  Back to cited text no. 7
    
8.
Marcos-Gómez G, Merchán-Herrera A, Gómez-Barrado JJ, de la Concepción-Palomino F, Vega-Fernández J, López-Mínguez JR. Silent left ventricular pseudoaneurysm and rupture to a second pseudoaneurysm. Rev Esp Cardiol 2005;58:1127-9.  Back to cited text no. 8
    


    Figures

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



 

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