Submitral Aneurysms Research Articles

Submitral left ventricular aneurysm: The location of the circumflex coronary artery in relation to the aneurysm influences the surgical approach and outcome

Submitral left ventricular aneurysms are rare forms of nonischemic aneurysm thought to be developmental in origin. Originally described in young male subjects of African ancestry,1 they occur in relation to the posterior mitral annulus, producing valve incompetence and left ventricular dysfunction. The widespread availability of echocardiography in recent years has made preoperative diagnosis possible.2 We focus on our experience with the surgical correction of this uncommon entity.

Submitral aneurysm of the left ventricle

Submitral aneurysms of the left ventricle were first reported from Nigeria and other African nations [1]. Several reports from Indian centers of small numbers of cases have highlighted their presentation with left ventricular dysfunction, heart failure and mitral regurgitation with poor outcome both on medical and surgical management [2, 3, 4]. We report two cases who had presented to our centre in the last six months, highlighting the wide spectrum in the presentation and outcome in this rare disease.

Left ventricular sub-valvar mitral aneurysms

We retrospectively reviewed the surgical treatment of 12 patients (nine female, mean age 16.1+/-8.7 years) with sub-mitral aneurysms managed in our institution between 1991 and 2002. We identified three groups of patients in accordance with the degree of posterior mitral annular involvement by the aneurysm. A single aneurysm neck was found in seven patients, multiple necks in two and involvement of the entire posterior mitral annulus in three patients. Involvement of the entire posterior annulus by the aneurysmal process has not been previously described. The mean age of this latter group 29+/-5.1 years was significantly older than the former (P=0.001), suggesting a possible progressive nature of sub-mitral aneurysms. An intracardiac surgical approach was used in six patients and a combined intra and extracardiac approach in the remainder. There was no operative mortality. The mitral valve was initially repaired in eight patients. Failure of closure of the aneurysm necessitating reoperation occurred in four patients (33.3%). An understanding of the inter-relationship between the aneurysm and mitral valve is essential for successful surgical repair. Histology of the aneurysm tissue showed rheumatic heart disease in two patients and tuberculosis in two patients. Hence, although sub-valvar aneurysms are thought to be congenital, a third of our patients had evidence of co-existent rheumatic heart disease or tuberculosis.

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

Submitral Aneurysm Is Not A False Aneurysm

To the Editor: I enjoyed reading the beautifully illustrated case report of submitral aneurysm by Kontozis et al.1 However, I questioned the appropriateness of the term “false aneurysm” used by the authors to describe the submitral left ventricular aneurysm. False aneurysm is a healed myocardial free-wall rupture of a myocardial infarct.2 Because the authors stated clearly that submitral left ventricular aneurysms are caused by a congenital defect in the posterior portion of …

Submitral left ventricular aneurysms: Anesthetic considerations

S UBMITRAL aneurysms occur in the left ventricle adjacent to the mltral annulus. They are the most common subannular aneurysms of the left ventricle. The aneurysms are often large and multiloculated and contain thrombi. They tend to grow into the pericardial space, behind the left atrium, bulging through its floor) A significant segment of the posterior mitral annulus is involved that leads to loss of support for the posterior leaflet with prolapse and consequent regurgitation 2 It may also compress the circumflex coronary artery, leading to angina pectoris or myocardial infarction. Submitral aneurysms are not uncommon in the black population of Africa, and occasional cases have been described m the white population outside of Africa. 2-6 They have also been reported in the Indmn population. 7 The incidence of this condmon is 1% to 2% of isolated mitral valve disease in the African population as reported by Antunes. I The cause is unknown but appears to be related to a defect or developmental weakness between the muscular ventricular wall and the fibrous annulus. The hemodynamlc impairment is related to the systolic expansion of the aneurysm, to valve regurgitation, or to both. The symptoms are those of congestive heart failure and angina pectorls. Occasionally they rupture, s Reported is an experience with two such patients and highlighted are the assocmted problems that might influence the successful anesthetic management of such patients. The authors believe this to be the first report describing the anesthetic management of such cases. A case of grant submitral aneurysm was reported about 6 years ago. 7 The patient died of low cardiac output syndrome after surgery However, the patient is not included in this report due to the unavailability of the anesthetic details.

Surgical management of ventricular tachycardia in subannular left ventricular aneurysm

Submitral left ventricular aneurysms typically affect young adults of African ancestry. These aneurysms are characterized by heart failure and mitral insufficiency, and occur in the absence of coronary disease. We report a rare case of symptomatic ventricular tachycardia in association with submitral left ventricular aneurysm (and no mitral insufficiency). Ventricular tachycardia was abolished by aneurysm resection and ventricular reconstruction. We suggest surgical management is indicated for ventricular tachycardia associated with this unusual condition, and may be curative.

Annular subaortic aneurysm resulting in sudden death

A subvalvular aneurysm in a 34-year-old black woman developed beneath the left coronary cusp of the aortic valve and extended in the epicardium between the aortic root and left atrium. She was asymptomatic until she expired suddenly from myocardial ischemia caused by compression of the circumflex coronary artery by the aneurysm. A review of the literature reveals 13 reports of subaortic and 58 submitral aneurysms but only two instances of myocardial infarction secondary to coronary artery compression by spontaneous subvalvular aneurysms in either the subaortic or submitral position.

Coexistence of congenital submitral andaortic sinus aneurysms

Coexistence of congenital submitral andaortic sinus aneurysms

Cross-sectional echocardiographic features of congenital submitral left ventricular aneurysms

Congenital submitral left ventricular aneurysm is a rare entity, seen predominantly in the natives of South and West Africa. We report two cases, highlighting the cross-sectional echocardiographic features in each case.

Submitral left ventricular aneurysms: Correction by a new transatrial approach

Submitral left ventricular aneurysm is a widely recognized but relatively unknown entity that occurs almost exclusively in African patients and is often associated with mitral regurgitation. In the past 2 1/2 years, nine patients with submitral aneurysm were operated on by a new transatrial approach that exposes the neck of the aneurysm through an incision in the floor of the left atrium (roof of the aneurysm). There were four female and five male patients and the mean age was 28 +/- 3 years (range 23 to 35 years). All patients but one had significant mitral valve regurgitation and were in New York Heart Association Class III or IV. All operations were performed with standard cardiopulmonary bypass. At operation the neck of the aneurysm was invariably found beneath the posterior mitral valve anulus, at any site between the anterolateral and posteromedial commissures. The transverse diameter was variable, replacing up to two thirds of this portion of the annulus. In one patient the aneurysm perforated into the left atrial cavity. The neck of the aneurysm was closed directly in all patients and all mitral valves were preserved. Comprehensive valvuloplasty, including a Carpentier ring, was required in four patients. One patient died on the operating table of an uncontrolled diffuse pericardial hemorrhage. The remainder were discharged from the hospital and have good mitral valve function postoperatively. The transatrial approach to the repair of submitral left ventricular aneurysms results in a lower operative mortality and morbidity and almost invariably permits conservation of the mitral valve.

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.