Ann Thorac Surg 2004;78:2171-2173
© 2004 The Society of Thoracic Surgeons
Case report
Mitral Valve Aneurysm With Infective Endocarditis
Changqing Gao, MD*,a,
Cangsong Xiao, MDa,
Bojun Li, MDa
a Department of Cardiovascular Surgery, PLA General Hospital, PLA Institute of Cardiac Surgery, Beijing, China
Accepted for publication August 6, 2003.
* Address reprint requests to Dr Gao, Department of Cardiovascular Surgery, PLA General Hospital, 28 Fuxing Rd, Beijing 100853, China
gao.cq301{at}263.net
 |
Abstract
|
|---|
A case of mitral valve aneurysm associated with infective endocarditis is reported. Two-dimensional echocardiography revealed a saccular structure in the anterior leaflet that bulged into the left atrium throughout the cardiac cycle. During operation, the vegetation on the commissure of the right and left aortic leaflet and a 3-mm perforation on the noncoronary leaflet were found. The mitral valve and aortic valve were replaced with mechanical prosthesis. Pathology of the excised valves showed inflammation. For this patient, we considered that the infected aortic regurgitant jet striking the ventricular surface of the anterior mitral leaflet could be the mechanism of the leaflet aneurysm.
|
Introduction
|
|---|
Mitral valve aneurysm (MVA) is uncommon and reported cases are rare and often the consequence of infective endocarditis. The mechanism of the aneurysm evolvement is not clearly established.
A case of MVA associated with infective endocarditis is reported. The patient, a 37-year-old man, was suffering from febrile (> 38°C) and fatigue after a cold, who was intermittently prescribed antibiotic therapy. The patient's temperature fluctuated, but his complaints gradually deteriorated. Eight months later he came to our hospital because of shortness of breath and palpitation after slight exertion and finally nocturnal dyspnea. Physical examination found diastolic murmur along the left sternal border and systolic murmur at the apex implying aortic and mitral regurgitation. Several Osler's nodes were also documented. Moderate cardiomegaly wasnoted in the chest roentgeno-gram. A transthoracic echocardiagram (TTE) revealed a vegetative mass attached to the noncoronary cusp, severe aortic insufficiency, and a saccular structure without perforation, which was also visualized on the anterior mitral leaflet and constantly protruded into the left atrium with moderate mitral insufficiency. The left ventricle was enlarged to 73 mm. After admission, large doses of penicillin were intravenously given for 1 month due to high fever and increased white blood cells until returning to normal. Blood cultures were negative, but hematological studies suggested active inflammation.
Operation was performed under moderate hypothermia in routine fashion. Through oblique aortotomy, the vegetation on the commissure of the right and left aortic leaflet and a 3-mm perforation on the noncoronary leaflet(Fig 1) were demonstrated. After resection of aortic leaf-lets and clearance of vegetation, an oval deficit of 5 mm in diameter on the anterior mitral leaflet was clearly visualized through aortotomy (Figs 2, 3). The left atrium was entered by the interatrial septum approach and the mitral valve was inspected. No rupture was found on the white thin wall of the MVA (20 x 20 x 15 mm) that was communicated with the left ventricle through its orifice. No visible evidence of endocarditis existed on the mitral leaflet (Figs 4, 5). After resection of the MVA, the mitral valve was past repair. The mitral valve was replaced with a 29-mm St. Jude mechanical prosthesis with the posterior mitral leaflet preserved and the prosthesis implanted in the aortic position. Postoperatively the patient received a large dosage of penicillin again and recovered uneventfully. He was discharged 10 days after the operation without any complications. Pathology of the excised valves showed inflammation.
View larger version (79K):
[in this window]
[in a new window]
|
Fig 2. Mitral valve aneurysm with oval deficit of 5 mm in diameter on the anterior mitral leaflet (shown from the aortic incision).
|
|
View larger version (114K):
[in this window]
[in a new window]
|
Fig 3. Mitral valve aneurysm with oval deficit of 5 mm in diameter on the anterior mitral leaflet resected.
|
|
View larger version (82K):
[in this window]
[in a new window]
|
Fig 4. Mitral valve aneurysm (20 x 20 x 15 mm) with a white thin wall (shown from the left atrial side).
|
|
|
Comment
|
|---|
Uncommon MVA is frequently associated with infective endocarditis involving the aortic valve [1–6]. An MVA is defined as a localized bulge of the mitral leaflet toward the left atrium with systolic expansion and diastolic collapse [7]. Because reports on MVA are published sporadically, the mechanism of its formation is not clear. Primary or secondary endocarditis from aortic infection, rheumatic disease, and other disorders causing connective tissue degeneration [4, 5] are the possible cause from which the strength of the mitral leaflet is weakened and the leaflet protrudes into the left atrium under the left ventricular pressure. There are also occasional reports of the MVA forming in patients without endocarditis, such as those with connective tissue diseases, including mitral valve prolapse, osteogenesis imperfecta, Marfan syndrome, and pseudoxanthoma elasticum [7–9]. However, in this patient we considered that the infected aortic regurgitant jet striking the ventricular surface of the anterior mitral leaflet could be the cause with a higher possibility because of the anatomic relationship between the aneurysm site and the aortic lesion, which contributes to a much higher frequency of involvement of anterior mitral leaflet aneurysm. In our patient, a 3-mm perforation on the noncoronary leaflet was found (Fig 1), which may cause an aortic regurgitant jet.
Diagnosis can be made by transesophageal echocardiogram or TTE, and transesophageal echocardiogram is more sensitive and accurate [10, 11]. Echocardiography shows MVA as a localized saccular bulge of the leaflet toward the left atrium and communication between the aneurysm and the left ventricle during the cardiac cycle [10, 12]. Mitral valve repair or replacement is indicated when aneurysm is ruptured or when the unruptured aneurysm is large or accompanied by significant regurgitation. The mitral valve can be repaired with autologous pericardium [13]. Conservation may be possible for small ones, but close follow-up is needed [10, 14]. It is suggested that MVA, which may be neglected by TTE preoperatively [15], should be carefully inspected at the time of aortic valve replacement due to endocarditis, because repair or replacement of the mitral valve may also be necessary. Transesophageal echocardiogram is an excellent method for diagnosing these aneurysms and may contribute significantly to management decisions.
|
References
|
|---|
- Reid CL, Chandraratna AN, Harrison E, et al. Mitral valve aneurysm: clinical features, echocardiographic-pathologic correlations. J Am Coll Cardiol. 1983;2:460–464[Abstract]
- Raval AN, Menkis AH, Boughner DR. Mitral valve aneurysm associated with aortic valve endocarditis and regurgitation. Heart Surg Forum. 2002;5:298–299[Medline]
- Kawai S, Oigawa T, Sunayama S, et al. Mitral valve aneurysm as a sequela of infective endocarditis: review of pathologic findings in Japanese cases. Cardiol. 1998;31(Suppl 1):19–33 discussion 34–6
- Piper C, Hetzer R, Korfer R, et al. The importance of secondary mitral valve involvement in primary aortic valve endocarditis; the mitral kissing vegetation. Eur Heart J. 2002;23:79–86[Abstract/Free Full Text]
- Mollod M, Felner KJ, Felner JM. Mitral and tricuspid valve aneurysms evaluated by transesophageal echocardiography. Am J Cardiol. 1997;79:1269–1272[Medline]
- Goh K, Yamamoto H, Inaba M, et al. Ruptured mitral valve aneurysm in a patient with quadricuspid aortic valve. J Cardiovasc Surg (Torino). 2000;41:393–394[Medline]
- Ruckel A, Erbel R, Henkel B, Kramer G, Meyer J. Mitral valve aneurysm revealed by cross-sectional echocardiography in a patient with mitral valve prolapse. Int J Cardiol. 1984;6:633–637[Medline]
- Edynak GM, Rawson AJ. Ruptured aneurysm of the mitral valve in a Marfan-like syndrome. Am J Cardiol 1963:674–7
- Lebwohl MG, Distefano D, Prioleau PG, Uram M, Yannuzzi LA, Fleischmaier R. Pseudoxanthoma elasticum and mitral valve prolaps. N Engl J Med. 1982;307:228–231[Medline]
- Vilacosta I, San Roman JA, Sarria C, et al. Clinical, anatomic, and echocardiographic characteristics of aneurysms of the mitral valve. Am J Cardiol. 1999;84:110–113[Medline]
- Christiaens L, Coisne D, Allal J, et al. Perforated aneurysm of the anterior mitral leaflet: late assessment with transesophageal echocardiography. J Heart Valve Dis. 1992;1:260–261[Medline]
- Shakudo M, Eng AK, Applegate PM, et al. Visualization of mitral valve aneurysm by transesophageal echocardiography. Echocardiography. 1990;7:551–554[Medline]
- Maier JH, Seward JB, Miller FA, et al. Aneurysms in the left ventricular outflow tract: clinical presentation, causes, and echocardiographic features. J Am Soc Echocardiogr. 1998;11:729–745[Medline]
- Gin KG, Boone JA, Thompson CR, Bilbey JH. Conservative management of mitral valve aneurysm. J Am Soc Echocardiogr. 1993;6:13–18
- Li YH, Lin JM, Lei MH, et al. Mitral valve aneurysm and infective endocarditis: a report of four cases. J Formos Med Assoc. 1995;94:499–502[Medline]
This article has been cited by other articles:
|
|
|
|
 
J. Hotchi, M. Hoshiga, T. Okabe, T. Nakakoji, T. Ishihara, T. Katsumata, and T. Hanafusa
Impressive Echocardiographic Images of a Mitral Valve Aneurysm
Circulation,
April 12, 2011;
123(14):
e400 - e402.
[Full Text]
[PDF]
|
|
|
|
|
|
|
O. Azevedo, F. Ferreira, J. Guardado, C. Duraes, I. Quelhas, A. Pereira, and J. Almeida
Mitral and aortic valve aneurysms secondary to infective endocarditis: impressive images of a rare echocardiographic finding
Eur Heart J Cardiovasc Imaging,
August 1, 2010;
11(7):
E28 - E28.
[Abstract]
[Full Text]
[PDF]
|
|
|
Top
Abstract
Introduction
