Ann Thorac Surg 2006;82:2294-2296
© 2006 The Society of Thoracic Surgeons
Case Reports
Left Ventricular Posterior Wall Pseudoaneurysm: A Rare Sequela of Mitral Valve Infective Endocarditis in a Chronic Patient of HLA-B27 Positive Spondyloarthritis
Vithalkumar Malleshi Betigeri, MS, MCha,
Rafeeq Abdul Kareem, MS, MCha,
Rajagopal Sadasivan Nair, MS, MCha,
Suresh Gangadharan Nair, MDb,*,
Prakash Kamath, MD, DMc,
Shiv Kumar Nair, MS, MCha
a Departments of Cardiovascular and Thoracic Surgery, Cochin, India
b Department of Cardiac Anesthesia, Cochin, India
c Department of Cardiology, Amrita Institute of Medical Sciences, Cochin, India
Accepted for publication February 3, 2006.
* Address correspondence to Dr Nair, Amrita Institute of Medical Science, Amrita Lane, Elamakkara PO, Cochin, 682 026 India. (Email: shivknair{at}aimshospital.org).
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Abstract
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Left ventricular posterior wall pseudoaneurysm after native mitral valve infective endocarditis is a very rare occurance. We report such a case in a patient with HLA-B27-associated spondyloarthritis and normal coronary arteries. Excision of the aneurysm with left ventricular reconstruction and mitral valve replacement resulted in an excellent outcome.
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Introduction
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Left ventricular pseudoaneurysms occur very rarely after native mitral valve endocarditis with less than 20 cases reported in the literature (PubMed). We report such a case with HLA-B27-associated spondyloarthritis, which might have resulted in pseudoaneurysm formation due to obliterative myocardial endarteritis, and which we believe has not yet been reported in the literature (Pub Med).
A 51-year-old man with chronic HLA-B27-associated spondyloarthritis was referred for mitral valve replacement for severe mitral regurgitation after native mitral valve endocarditis. He had been treated with appropriate antibiotics for 4 weeks and had an uneventful recovery. On preoperative evaluation 2 weeks after cessation of antibiotic therapy, his transthoracic echocardiogram revealed a large posterior left ventricular pseudoaneurysm (Fig 1) with severe mitral regurgitation and global hypokinesia (ejection fraction, 40%), not seen on previous echocardiogram. Transesophageal echocardiogram and left ventriculography confirmed the diagnosis. Coronary arteriography done concurrently showed no obstructive lesions.
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Fig 1. Preoperative transthoracic echocardiogram showing posterior wall aneurysm. (Ao = aorta; LA = left atrium; LV = left ventricle.)
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Through a median sternotomy, cardiopulmonary bypass was established using aorto-bicaval cannulation. Dense intrapericardial adhesions were lysed after application of an aortic cross clamp. A large, thin-walled aneurysm measuring 7 x 5 cm arose from the posterior left ventricular wall (Fig 2). The aneurysm was incised longitudinally and the neck was identified 1.5 cm below the mitral annulus and was measured at 6 x 4 cm. A Fontan stitch using 2-0 Prolene (Ethicon, Somerville, NJ) was used to circumferentially narrow the neck to 2.5 cm, and a sandwich patch of Gore-Tex (W.L. Gore & Assoc, Flagstaff, AZ) with pericardium on the inside was used for left ventricular reconstruction. Mitral valve replacement with Starr Edwards mechanical mitral prosthesis (Edwards Lifesciences, Irvine, CA) was done through a left atrial approach and no abscess could be seen involving the annulus or the left ventricular myocardium. The patient was uneventfully weaned off cardiopulmonary bypass and made an uneventful recovery. At 1-year follow-up the patient is in New York Heart Association functional class I. Transthoracic echocardiogram revealed normal prosthetic valve function with an ejection fraction of 55% and no evidence of aneurysm or patch leak (Fig 3). Histology of the mitral valve showed chronic inflammatory changes and the aneurysm was devoid of any structural elements of the normal cardiac wall.
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Fig 2. Intraoperative diagram with large posterior left ventricular pseudoaneurysm. (LV post. wall = left ventricle posterior wall.)
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Fig 3. Follow-up transthoracic echocardiogram with mitral valve prosthesis (MVP) in situ and intact sandwich patch of Gore-Tex (W.L. Gore & Assoc, Flagstaff, AZ) with pericardium. (LA = left atrium; LV = left ventricle; RV = right ventricle).
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Comment
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Left ventricular pseudoaneurysm typically arises from the posterior wall and requires early surgical intervention as histopathologically they have no myocardial fibres and are prone to rupture [1]. Mitral valve infective endocarditis has been implicated as a cause of pseudoaneurysm formation [2]. Pseudoaneurysms after infective endocarditis are rare. Our patient had associated HLA –B27 spondyloarthritis; besides the joints, the heart is the major target for HLA-B27-associated inflammatory disease process [3]. Intimal proliferation of the small arteries resulting in obliterative endarteritis and fibrosis of myocardium might have contributed to left ventricular pseudoaneurysm formation [3]. Other possible mechanisms of aneurysm formation include penetration of an abscess through the myocardium [4] and the abrasion of the ventricular endocardium by vegetations resulting in perforative ulceration [5]. Twenty percent to 30% of cases with native valve endocarditis develop abscesses [5]. However we found no vegetation or abscess in our patient. We can only postulate that the combination of native valve endocarditis with HLA–B27-associated inflammatory disease process involving the myocardium resulted in pseudoaneurysm formation in our patient.
Submitral left ventricular aneurysm is differentiated from a posterior left ventricular pseudoaneurysm by its location adjoining the posterior mitral annulus and associated defect in the fibrous layer [6]. Spasm of the normal coronaries has been implicated to cause myocardial infarction and subsequent aneurysm formation [7]. However these patients give a history of angina or infarction.
Our patient had no evidence of aneurysm formation on transthoracic echocardiogram or transesophageal echocardiogram while being treated for his infective endocarditis. On follow-up, 2 weeks after cessation of antibiotic therapy, a pseudoaneurysm was detected on transthoracic echocardiogram. Transesophageal echocardiogram, which provides an unobstructed view of the posterior aspect of the heart, confirmed the diagnosis. Computed tomography and magnetic resonance imaging can be used for diagnostic imaging as they show an abrupt ending of the myocardial wall at the border of the aneurysm [8].
Pseudoaneurysms have been repaired by both the right and left thoracotomy approach in a re-do situation. We used the median sternotomy and repaired the aneurysm by the external approach as it provided unimpeded access for excision of the aneurysm with restoration of the left ventricular wall and mitral valve replacement through a standard left atrial approach. Although most pseudoaneurysms have a narrow neck, wide mouth aneurysms such as those seen in our patient have been reported [9]. Using the Fontan stitch to narrow the neck was necessary to restore left ventricular geometry.
Left ventricular reconstruction using Dor’s endoaneurysmorrhaphy has improved left ventricular function at 1-year follow-up.
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References
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- Fiorilli R, Tomasco B, Tesler UF. Pseudoaneurysm of the left ventricle- a rare sequela to mitral valve endocarditis Tex Heart Inst J 1999;26:309-311.[Medline]
- Bergfeldt L. HLA-B27–associated cardiac disease Ann Intern Med 1997;127(8 Part 1):621-629.[Abstract/Free Full Text]
- Tingleff J, Egeblad H, Gotzsche CO, Baandrup U, Kristensen BO, Pilegaard H, et al. Perivalvular cavities in endocarditis: abscesses versus pseudoaneurysms?A transesophageal Doppler echocardiographic study in 118 patients with endocarditis. Am Heart J 1995;130:93-100.[Medline]
- Thomas D, Desruennes M, Jault F, Isnard R, Gandjbakhch I. Cardiac and extracardiac abscesses in bacterial endocarditis Arch Mal Coeur Vaiss 1993;86(12 Suppl):1825-1835.[Medline]
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- Asha M, Pradeep GN, Mukundan S, Gurijala S, Abraham KA. Left ventricular pseudoaneurysm caused by coronary spasm, myocardial infarction and myocardial rupture Tex Heart Inst J 2002;29:122-125.[Medline]
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- Hirasawa Y, Miyouchi T, Sawamura T, Takiya H. Giant left ventricular pseudoaneurysm after mitral valve replacement and myocardial infarction Ann Thorac Surg 2004;78:1823-1825.[Abstract/Free Full Text]
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Abstract
Introduction
