Subaortic Aneurysm Research Articles

P1301 Opposite outcomes of two equally destructive forms of infective endocarditis

Abstract Introduction Infective Endocarditis is a complex entity with great variability of clinical manifestations and a broad spectrum of complications. The prognosis depends not only on the baseline characteristics of the patient, but also on the agent and the complications, both local and systemic, with clinical repercussion. Two clinical cases are presented. A 67-year-old woman with history of uncharacterized aortic valve disease, presented in the emergency department with a 3-month evolution of asthenia and anorexia, and ocasional fever. She presented pallor, with a systolic murmur II/VI audible throughout the precordium and no other abnormalities in physical examination. Blood tests showed Hb 9g/dL with normal MCV and MCH, no leucocytosis, CRP 132mg/L, mild elevation of troponin I (0.32ng/ml; N <0.04ng / ml) and erythrocyturia. Transthoracic and transesophageal echocardiograms (TTE and TEE) showed a mass on the aortic valve suggestive of vegetation, conditioning a moderate aortic regurgitation (AoR) and mitroaortic pseudoaneurysm. Another 49-year-old female patient, submitted during childhood to a subaortic aneurysm, intraventricular comunication, AoR and aortic coarctation repair, presented with deterioration of functional and neurological status, associated with fever and lower limb edema. At examination she had tachypnea, tachycardia, pallor, aortic systolic murmur and signs of pulmonary congestion. Blood tests had leukocytosis and neutrophilia, CRP 174mg/L, Hb 9.6g/dL, elevation of liver enzymes, spontaneous INR 1.4 and no renal damage. TTE and TEE showed a mobile vegetation attached to the ventricular face of the aortic valve with major AoR and perivalvular abscess fistulized to the left ventricle. Both patients were treated with empirical therapy with gentamicin, ampicillin, and flucloxacillin. The first case evolved with hemodynamic stability, without heart failure or distant embolization. It was isolated a multisensitive Strept. gordonii and antibiotic therapy was de-escalated to ampicillin alone. In the second case, the patient showed rapidly progressive clinical deterioration with hypoxemic respiratory failure and cardiogenic shock requiring vasopressor support, and was urgently presented to a surgical center. No microorganism was isolated and broad-spectrum antibiotic therapy was maintained. She eventually died before she underwent valve surgery. On the other hand, in the first case, 6 weeks of antibiotic therapy were completed and aortic valve replacement surgery was performed without complications. She was discharged without cardiovascular symptoms and has an unremarkable follow-up of 6 months. With these cases it was possible to demonstrate the variability of presentations and prognosis of the same entity, even if ab initio with equally severe local complications. The initial stratification of the prognosis, the initiation of early treatment and the adequacy of the surgical time for intervention are of importance. Abstract P1301 Figure. Imaging study of endocarditis

Congenital Mitral Aortic Intervalvular Fibrosa Aneurysm with Submitral Aneurysm

Congenital aneurysm of the mitral aortic intervalvular fibrosa (MAIVF) is a relatively rare condition. It was initially described in the African population and subsequently reported in other racial groups. Many of the subaortic aneurysms arise from the MAIVF; association with submitral aneurysm (SMA) is even rare. They more commonly occur as a pseudoaneurysm of the MAIVF-P, which is usually due to a complication of endocarditis or aortic valve surgery. Diagnosis is usually with echocardiography, and complete confirmation and anatomical assessment are done by computerised tomography and cardiac magnetic resonance imaging, which are useful for surgical evaluation. Surgery is the only treatment when it is large or symptomatic or has related complications, such as rupture, compression of adjacent structures, embolic events, mitral regurgitation, or heart failure. Here, case is presented of a congenital variety of MAIVF aneurysm with congenital SMA, in a 31-year-old female. She presented with breathlessness. She had mitral regurgitation, and had to undergo surgical repair and mitral valve replacement. This may be the first case reported of a congenital MAIVF aneurysm with a congenital SMA.

Submitral Aneurysm: A Rare Cause of Complete Heart Block

Subvalvular left ventricular (LV) aneurysms are rare and are of two types – subaortic and submitral. More commonly, they are submitral in position. Submitral aneurysms (SMAs) are most commonly located below posterior mitral leaflet (PML), whereas subaortic aneurysms are present below intermediate portion of the left aortic sinus. SMA was first described by Corvisart in 1812, and since then, only about 100–120 cases have been described worldwide. Aneurysmal dilatation in submitral position behind PML that communicates with left ventricle helps in making the diagnosis. Color Doppler echocardiography reveals the severity of mitral regurgitation. Transesophageal echocardiography and contrast-enhanced computed tomography (CT) are helpful in diagnosis in cases of acute rupture of SMA, and contrast-enhanced CT helps in evaluation of coronaries. Surgical resection is the definitive treatment for these aneurysms. Our special case presented with complaints of giddiness and presyncope and was diagnosed as complete heart block on electrocardiogram and was then diagnosed as having a large SMA on two-dimensional echocardiogram with LV dysfunction. Usually, SMAs present with dyspnea, pansystolic murmurs due to mitral regurgitation, fever secondary to infective endocarditis, or as thromboembolism. However, this patient presented symptoms of complete heart block. To conclude, SMA should be considered in differential diagnosis of mitral regurgitation with LV dysfunction and heart failure in young patients. Although complete heart block is uncommon in these patients, it should be kept in mind.

Idiopathic giant subaortic left ventricular aneurysm causing extrinsic compression of left coronary circulation and right pulmonary artery

Introduction: Myocardial infarction, dilated cardiomyopathy, sarcoidosis, Chaga's disease and myocarditis are recognized causes of left ventricular (LV) aneurysm. Idiopathic LV aneurysms are rare and we describe here one of its rare presentation. Case report description: A 45 year male presented with exertional angina for the past 1 year, with acute exacerbation since one day. His electrocardiogram (ECG) showed ST depression in infero-lateral leads and elevation in lead aVR and V1. Troponin I was negative with cardiomegaly on chest radiograph. Echocardiogram showed enlarged LV with hypokinesia involving antero-lateral wall, LV ejection fraction was 35%. Additionally there was a narrow neck aneurysm arising from the LV outflow tract which was multilobulated and extended anterosuperiorly and laterally causing dynamic compression of right pulmonary artery (RPA). CT angiography also showed similar findings. Coronary angiogram showed severe external compression of left main coronary artery extending up-to mid part of left anterior descending artery and proximal part of left circumflex artery. Surgical aneurysmectomy was done which normalized the LV function on follow up, but residual aneurysm persists requiring a redo surgery. ![Figure][1] Figure 1 Discussion: Idiopathic LV aneurysm is rare, but well recognized. It usually presents as ventricular tachyarrhythmias or sudden cardiac death. In our patient a giant multilobulated subaortic aneurysm caused extrinsic compression of RPA and left coronary circulation leading to angina. Normalization of LV function at followup suggests relief of external compression of the coronaries. Conclusion: We present here the first case report of a large idiopathic subaortic left ventricular aneurysm causing extrinsic compression of left coronary circulation and RPA manifesting as coronary artery disease. [1]: pending:yes

Pseudoaneurysm of mitral-aortic intervalvular fibrosa in a child: Demonstration by MDCT and MRI

Subaortic left ventricular outflow tract pseudoaneurysms are rare lesions that are associated with aortic valve diseases, infective endocarditis, trauma or surgery. We present dynamic multidetector computerized tomography and cine magnetic resonance imaging features of a case of subaortic aneurysm arising from interaortic-mitral valvular region in a child with past history of infective endocarditis.

Congenital Subaortic Left Ventricular Aneurysm Diagnosed by 64-slice Multidetector-Row Computed Tomography

In this report, we describe a very rare case of a congenital subaortic left ventricular aneurysm in an 80-year-old patient. Cardiac computed tomography imaging is a reliable and noninvasive tool for diagnosis and follow-up of subaortic aneurysms.

Development of a Subaortic Aneurysm Secondary to Disseminated Tuberculosis in a Child

Subvalvular aneurysms of the left ventricle are very rare and often the cause is uncertain. Most of the cases of subvalvular left ventricular aneurysms described in the literature are due to congenital weakness of the fibromuscular annuli. We describe a unique case of a child with a tuberculous subaortic aneurysm observed at different stages of development by serial transthoracic echocardiography. The patient underwent successful cardiac surgery after the initial conservative treatment for tuberculosis.

Congenital left ventricular subaortic aneurysm in an asymptomatic child

A newborn was referred to our department, due to the presence of a cardiac murmur. Echocardiographic study showed a small membranous ventricular septal defect and a yuxta-aortic mass. In the follow-up, patient remained asymptomatic, ventricular septal defect closed, and yuxta-aortic mass increase in size with somatic growth. A transesophageal echocardiography was carried out, showing a fibrotic and dyskinetic left ventricular subaortic aneurysm of 19×18 mm. Given that the patient remained asymptomatic, a conservative approach was adopted. Congenital left ventricular subaortic aneurysm is an infrequent entity, and rupture, endocarditis, coronary compression, thromboembolism, arrhythmias and aortic insufficiency are some of its complications, but, as in our patient, if aneurysm is not associated with complications, patient is asymptomatic, and aneurysm growth is not very important, a conservative approach can be adopted, with a close surveillance.

Subvalvular Left Ventricular Aneurysms

Subvalvular left ventricular aneurysms can be subaortic or submitral with variable etiology. This is a retrospective study of 19 subvalvular aneurysms seen in 16 cases. There were 12 isolated subaortic aneurysms, 3 isolated submitral aneurysms, and in 1 case with multiple subaortic and submitral aneurysms. Subaortic aneurysms were associated with infective endocarditis, while there seems to be a strong association between submitral aneurysms and tuberculosis. Five cases of subvalvular aneurysm has associated aneurysm sinus of Valsalva—this association suggests a congenital weakness in the attachment of aortic and mitral annuli to the underlying myocardium. Cardio Pathol 2000;9:267–271

Absence of adenosine-induced chest pain after total cardiac afferent denervation

tic regurgitation, but no effect on mitral valve function. The presence of both submitral and subaortic aneurysm has been reported in the same patient.‘t2 In a description of a transatrial approach to these aneurysms in 9 patients, Antunes recommended a posterior incision, because in all of his patients, the neck was located in the posterior annulus. Failure to appreciate an anterior position, as in 2 of the present patients, may result in an inability to adequately expose and ligate the neck of the aneurysm. Hemodynamic impairment is related to valvular regurgitation, systolic expansion of the aneurysm,’ or in very few cases, mitral inllow obstruction by the aneurysm! The present study is the lirst to document preoperatively rupture of the aneurysm into the left atrium as another mechanism of volume overload. Accurate demonstration of the neck of the aneurysm is crucial, because surgical success is determined by complete closure of the neck. Optimal demonstration of anatomic relations of the aneurysm was best achieved in the present patients by the horizontal-plane basal 4chamber and longitudinal views of the mitral valve by scanning it through its entire mediolateral width. In using these views, the location of the neck, and the direction and extent of the body of the aneurysm could easily be determined. Furthermore, with the addition of color flow Doppler, the mechanism of mitral regurgitation, and the contribution of the aneurysm to the degree of volume overload were accurately defined. Therefore, we conclude that: (1) TEE is a useful imaging modality in patients with congenital submittal aneurysms; (2) contrary to previous reports, these aneurysms may originate from the anterior mitral annulus, necessitating a different surgical approach; and (3) rupture into the left atrium may not be uncommon.

Role of transesophageal echocardiography in diagnosis of subaortic aneurysm

Congenital subaortic annular aneurysm is a rare condition that has most frequently been reported among black people. 1,2 Frequently, an accurate antemortem or presurgical diagnosis cannot be made because of the peculiar anatomic location of this lesion. 1–4 Angiography may fail to show details important to the surgical approach to the patient, and transthoracic echocardiography may also miss the diagnosis. 5–7 Recently, it has been reported that transesophageal echocardiography (TEE) can define aortic annular abscesses more accurately than transthoracic echocardiography. 8 The present report summarizes our experience with subaortic aneurysm with emphasis on the role of TEE in the early diagnosis of subaortic aneursym.

Subaortic aneurysm in infective endocarditis

Subaortic aneurysm in infective endocarditis

Left ventricular outflow tract to left atrial communication secondary to rupture of mitral-aortic intervalvular fibrosa in infective endocarditis: Diagnosis by transesophageal echocardiography and color flow imaging

Infection of the mitral-aortic intervalvular fibrosa occurs most commonly in association with infective endocarditis of the aortic valve. Infection of the aortic valve results in a regurgitant jet that presumably strikes this subaortic interannular zone of fibrous tissue and produces a secondary site of infection. Infection of this interannular zone then leads to the formation of subaortic abscess or pseudoaneurysm of the left ventricular outflow tract. This infected zone of mitral-aortic intervalvular fibrosa or subaortic aneurysm can subsequently rupture into the left atrium with systolic ejection of blood from the left ventricular outflow tract to the left atrium. This report describes the echocardiographic findings in three patients with pathologically proved left ventricular outflow tract to left atrial communication. Precise preoperative diagnosis is important, and this lesion should be differentiated from ruptured aneurysm of the sinus of Valsalva and perforation of the anterior mitral leaflet. Transthoracic echocardiography using color flow imaging and conventional Doppler techniques may show an eccentric mitral regurgitation type of signal in the left atrium originating from the region of the left ventricular outflow tract. However, transesophageal echocardiography provides an accurate preoperative diagnosis and should be used intraoperatively during repair of such lesions.

Aortic and mitral discontinuity with congenital subaortic aneurysm and normally connected great arteries: echocardiographic diagnosis in life

A newborn with preductal coarctation and ventricular septal defect had a subaortic aneurysm which protruded into the left atrium causing intractable pulmonary oedema. The subaortic aneurysm was congenital. It was clearly identified by cross-sectional echocardiography which, in serial studies, showed it to be increasing in size. Predisposing to its development was the wide area of aortic and mitral discontinuity in association with the concordant ventricular connexion of the great arteries. The child remained in worsening pulmonary oedema after relief of the coarctation and banding of the pulmonary trunk and died after attempted relief of the left atrial obstruction.

Repair of complex subvalvular aortic aneurysm with a valved conduit

A subaortic annular aneurysm involving three fourths of the annular circumference was repaired with a valved conduit to which a Teflon felt flange was attached. This unique prosthetic repair assured a strong stable repair and uncompromised coronary flow otherwise unobtainable with previously described repairs.

Congenital Aneurysms Adjacent to the Anuli of the Aortic and/or Mitral Valves

The unusual occurrence of non-infected submitral and aortic aneurysms developing sequentially in an adult prompted us to review the pathogenesis of congenital aneurysms adjacent to the aortic and mitral valves. The findings support the suggestion that subvalvular aneurysms, like aortic sinus aneurysms, are a result of a congenital defect at the valve anulus. Submitral aneurysms occur only subjacent to the posterior leaflet. Whereas aortic sinus aneurysms may arise from any of the three sinuses, subaortic aneurysms occur only under the intermediate portion of the left aortic sinus. In the absence of rupture, the clinical presentation of these aneurysms results from valvular insufficiency or compression of the left coronary artery or of the conduction system.

Echocardiographic Examination in Aortic Regurgitation: Subaortic Aneurysm and Flail Aortic Leaflet

Echocardiographic examination of the left ventrincular outflow tract in a patient with aortic regurgitation revealed distinct and unusual findings representing diastolic prolapse of an aortic leaflet, in association with a subaortic aneurysm.

Repair and long-term follow-up of a subaortic annular aneurysm

Repair and long-term follow-up of a subaortic annular aneurysm