Pseudoaneurysm of the mitral-aortic intervalvular fibrosa. A new comprehensive review

Thirty-three-year follow-up of pseudoaneurysm of the mitral-aortic intervalvular fibrosa without surgical treatment: a case report and literature review

BACKGROUND

Pseudoaneurysm of the mitral-aortic intervalvular fibrosa (PMAIF) is a rare complication of infective endocarditis or aortic valve surgery. Surgical treatment is suggested, but the long-term follow-up of conservative management remains unclear.

CASE PRESENTATION

A 33-year follow-up of a patient who developed PMAIF six years after aortic valve replacement is reported. The patient presented to our center with dyspnea, and the echocardiography revealed an ejection fraction of 20% and a PMAIF measuring 7 × 10 mm. Despite being advised to undergo surgery, the patient declined due to fear of surgical outcomes. Consequently, conservative treatment with close observation but without surgery was initiated. During the 33-year follow-up period, the patient did not experience any adverse health effects.

CONCLUSION

Surgical intervention should be considered whenever the PMAIF is diagnosed. However, in any case that the surgery was not applicable, conservative management might lead to long-term survival, based on this and similar case reports in the literature.

Pseudoaneurysm of mitral-aortic intervalvular fibrosa with rupture: a case report

BACKGROUND

Mitral-aortic intervalvular fibrosa (MAIVF) is a fibrous region connecting the anterior mitral leaflet (AML) and aortic valve. Pseudoaneurysm of the MAIVF is a rare condition that has been reported as a sequela of infective endocarditis (IE) and surgical trauma. Here, we report a case of a ruptured pseudoaneurysm of the MAIVF, along with some literature reviews.

CASE PRESENTATION

A 65-year-old man diagnosed with moderate aortic regurgitation five years previously had a fever of unknown origin. He suddenly developed headache and apraxia and was transported to our hospital. He was diagnosed with intracranial hemorrhage and admitted. One week after admission, echocardiography revealed aorto-mitral discontinuity and protrusion with severe regurgitant flow from left ventricular outflow tract to the left atrium. The AML was suspected to have ruptured. However, intraoperatively, the AML structure was preserved. A ruptured pseudoaneurysm of the MAIVF was also observed. Therefore, we successfully performed pseudoaneurysm repair using a bovine pericardial patch, aortic valve replacement, and mitral annuloplasty.

CONCLUSIONS

P-MAIVF is a rare but potentially life-threatening complication of IE, for which timely diagnosis and prompt appropriate therapeutic intervention are required. In the present case, although neither obvious active IE nor history of previous IE could be identified, healed IE was considered based on the clinical course. The patient had intracranial hemorrhage (ICH) with well-controlled heart failure and underwent elective surgical repair more than one month after the onset of ICH, while the clinical course after the surgical procedure was uneventful.

Pseudoaneurysm of Mitral-Aortic Intervalvular Fibrosa Imitating a Rhabdomyoma in a Fetus

•P-MAIVF may present prenatally. •Location of and color flow into an atrial mass raises suspicion for P-MAIVF. •The natural history of this presentation is still uncertain.

Pseudoaneurysm of the mitral-aortic intervalvular fibrosa: a rare case after percutaneous transluminal coronary angioplasty

BACKGROUND

Pseudoaneurysm of the mitral-aortic intervalvular fibrosa (P-MAIVF) is an uncommon but potentially life-threatening condition. The most common pathogenic factors of P-MAIVF are infective endocarditis and surgical valve operation. Here, we report a rare case of P-MAIVF which occurred one year after percutaneous transluminal coronary angioplasty (PTCA).

CASE PRESENTATION

A 31-year-old man developed a P-MAIVF one year after PTCA. Transthoracic echocardiography (TTE) revealed a pseudoaneurysm between the aortic root and the left atrium. Three-dimensional transesophageal echocardiography (3D-TEE) clearly demonstrated the orifice of the pseudoaneurysm. This case was initially diagnosed by ultrasound, and the prognosis was good after surgical repair.

CONCLUSIONS

We report a rare case of P-MAIVF that occurred one year after PTCA.

Incidental pseudoaneurysm of the mitral-aortic intervalvular fibrosa in asymptomatic patient: A case report

Pseudoaneurysm of the mitral-aortic intervalvular fibrosa (P-MAIVF) can be a rare but life-threatening complication of infective endocarditis, cardiac surgery, or blunt chest trauma. Congenital heart diseases especially in young patients are reported as additionally predisposing factors. We present the case of an asymptomatic 52 years-old male with bicuspid aortic valve and gastrointestinal polyposis syndrome in whom a P-MAIVF was incidentally detected. The patient successfully underwent pseudoaneurysm surgical repair and aortic valve replacement and despite no evident causes were found we hypothesized addiotional underlying mechanism of P-MAIVF.

Prenatally diagnosed pseudoaneurysm of mitral-aortic intervalvular fibrous area

The mitral-aortic intervalvular fibrosa (MAIVF) is an avascular, fibrous structure that provides continuity between the anterior leaflet of the mitral valve and the aortic valve. Pseudoaneurysm of the MAIVF is rare and has been most commonly described in adults and, more rarely, in children following cardiac surgery or endocarditis. Few reports have been published on cases with congenital pseudoaneurysm of the MAIVF. Here, we describe five cases of congenital pseudoaneurysm of the MAIVF identified prenatally and an additional six cases diagnosed postnatally. This is an unusual finding of varying clinical significance, which can be isolated or associated with complex congenital heart disease but, importantly, can be identified and monitored in the fetus. © 2022 International Society of Ultrasound in Obstetrics and Gynecology.

Complete postsurgical left ventricular-aortic discontinuity and pseudoaneurysm formation

BACKGROUND

Left ventricular outflow tract pseudoaneurysm is a rare but potentially fatal complication of aortic valve replacement, infective endocarditis (IE), and suture dehiscence. Left ventricular-aortic discontinuity is a severe and uncommon manifestation of IE. For patients who have a long-standing history of endocarditis, periannular lesions in the aortic valve may rupture, leading to the rare occurrence of complete, or total, left ventricular-aortic discontinuity.

METHODS

We present a case of complete postoperative left ventricular-aortic discontinuity and massive circumferential left ventricular outflow tract pseudoaneurysm discovered during a 3-month follow-up visit. Appropriate consent was obtained from all parties before submission of this case report.

RESULTS

Postoperative cardiac computed tomography of a patient demonstrated dehiscence of a recently placed surgical aortic valve from the left ventricular outflow tract, with massive circumferential pseudoaneurysm formation. Only a small remnant of the membranous interventricular septum connected the aortic root to the heart, informing the diagnosis of complete left ventricular-aortic discontinuity.

CONCLUSION

The clinical presentation of a left ventricular outflow tract pseudoaneurysm with concomitant left ventricular-aortic discontinuity is commonly nonspecific or clinically silent; thus, it requires a high index of suspicion and use of multimodality imaging for diagnosis and management.

An abscess of mitral aortic intervalvular fibrosa mimicking an intracardiac mass

BACKGROUND

Abscess of the mitral-aortic intervalvular fibrosa (MAIVF) is a rare occurrence, with its most frequently described causative associations being active or prior endocarditis, prosthetic valves, or native valves with anomalies. We report a case of infective endocarditis (IE) complicated by an abscess of the MAIVF without valvular involvement. This case highlights the importance of this rare clinical entity and of the multimodality imaging approach in reaching an accurate diagnosis and differential diagnosis.

METHODS AND RESULTS

A 35-year-old male presented with fatigue and intermittent high-grade fever for a 2-week duration. IE was suspected based on a clinical exam. Transthoracic echocardiography (TTE) demonstrated heterogeneous mass with a size of about 2.9 cm × 2.3 cm coming from the MAIVF, mimicking an intracardiac mass. Color Doppler flow Imaging showed the mass without communication with the surrounding cardiovascular cavities. Cardiac computed tomography angiography (CCTA) revealed a large low-density mass without any enhancement, which was situated adjacent to the left ventricular tract with a severely compressed left atrial chamber. The patient underwent cardiac mass removal under extracorporeal circulation. During the procedure, a large abscess was found to be located in MAIVF. The postoperative course was uneventful.

DISCUSSION

The abscess of MAIVF is a rare entity with a high risk of developing the pseudoaneurysm of MAIVF (p-MAIVF). The periaortic spread of the abscess is a dynamic process in which the inflammation of the deep tissue causes, in the first stage, a MAIVF thickening, which eventually progresses with the formation of an abscess, and subsequently, a pseudoaneurysm. Complications of p-MAIVF include rupture into the left atrium, aorta, or pericardial space leading to hemopericardium, tamponade, and death. The major differential diagnosis for abscess of MAIVF includes p-MAIVF an intracardiac mass. TTE plays a key role in the diagnosis and differential diagnosis of abscesses of MAIVF. CCTA can be a useful adjunct to further characterize abscess spread, three-dimensional spatial relationships with other cardiac structures for preoperative planning, as well as in the evaluation of potential complications such as coronary artery compromise and communication with the aorta, left atrium, or pericardial space. Surgical management is recommended in complicated, symptomatic patients to prevent further expansion of abscesses or pseudoaneurysms.

CONCLUSION

The abscess of MAIVF is a rare complication of endocarditis and surgical trauma in the MAIVF area, TTE remains a first-line imaging modality for clinically suspected periaortic abscess or other IE complications. CCTA has a complementary role to echocardiography in identification, characterization, and preoperative planning.

Transcatheter aortic valve implantation in patients with unruptured aortic root pseudoaneurysm: an observational study

AIMS

Unruptured aortic root pseudoaneurysm (UARP) is a rare complication of aortic valve endocarditis. Infectious spread to the valvular annulus or myocardium can cause septic complications that manifest as wall thickening, and spontaneous abscess drainage leads to pseudoaneurysm formation. We report the first patient series in which transcatheter aortic valve implantation (TAVI) using a single valve-resolved aortic valvulopathy associated with UARP was performed.

METHODS

At our center, from December 2017 to October 2019, 138 patients underwent TAVI for aortic valve stenosis and/or regurgitation, 20 of whom (12 female patients, 8 male patients) had associated incidental UARP and were considered as our study population. The average age of these patients was 76.9 ± 5.2 years. All patients were assessed using preprocedural and postprocedural multimodality imaging, including transthoracic echocardiography, transesophageal echocardiography, and cardiac computed tomography angiography (CCTA).

RESULTS

In all cases, the final angiographic examination showed correct valve positioning with complete coverage of the false aneurysm. Post-TAVI CCTA showed presence of total or subtotal UARP thrombosis. The mean follow-up period was 17.5 months (12-23 months). During follow-up, imaging showed normal prosthetic valve function, no significant leakage (trace or mild), and complete UARP exclusion in all patients, without any complications.

CONCLUSION

In conclusion, percutaneous valve positioning can simultaneously solve pseudoaneurysm complications by excluding the sac and promoting thrombosis.

Surgical treatment for accidentally discovered pseudoaneurysm of the mitral-aortic intervalvular fibrosa with bicuspid aortic valve, ascending aortic aneurysm, and myocardial ischemia: a case report

Background

Pseudoaneurysm of the mitral-aortic intervalvular fibrosa (P-MAIVF) is a rare complication of infective endocarditis and aortic valve replacement. Ruptured P-MAIVF and angina due to compression of the coronary arteries are severe complications of this condition.

Case presentation

We report a case of P-MAIVF that was diagnosed accidentally during a routine checkup. The patient was asymptomatic; however, she had a systolic murmur. She had a history of infective endocarditis, which was treated conservatively without open-heart surgery. In addition, she was diagnosed with aortic valve stenosis, aortic valve regurgitation, bicuspid aortic valve, right coronary artery stenosis, and an ascending aortic aneurysm. She was treated with surgery, which involved patch closure of P-MAIVF with aortic valve replacement, coronary artery bypass grafting, and ascending aorta replacement. After the operation, echocardiography showed no leakage from the P-MAIVF.

Conclusions

It is necessary to have knowledge of P-MAIVF. Following up cases of infective endocarditis and post-aortic valve replacement using echocardiography is important for both, diagnosing P-MAIVF and preventing serious complications such rupture and angina.

Native Aortic Valve Endocarditis Complicated by Splenic Infarction and Giant Mitral-Aortic Intervalvular Fibrosa Pseudoaneurysm-A Case Report and Brief Review of the Literature

Background: Pseudoaneurysm of the mitral-aortic intervalvular fibrosa (P-MAIVF) is an unusual complication related to various injuries or conditions which involve the mitro-aortic region; it communicates with the left ventricular outflow tract and is associated with a high-risk of redoubtable complications or sudden death. The cerebral and splenic localizations are frequently seen as manifestations of systemic embolism in infective endocarditis. Currently, there are no specific recommendations related to the diagnosis, management, treatment, or further evolution of patients with P-MAIVF and concomitant splenic infarction. This paper presents the case of a 43-year-old Caucasian woman with a late diagnosis of mixed bicuspid aortic valve disease, affected by an under-detected and undertreated episode of infective endocarditis leading to asymptomatic P-MAIVF. Prime clinical and imagistic diagnosis of splenic infarction indicated further extended investigations were required to clarify the source of embolism. Methods: Integrated multimodality imaging techniques confirmed the unexpected diagnosis of P-MAIVF. Results: The case had a fatal outcome following an uncomplicated yet laborious cardiac surgery. Patient death was attributed to a malignant ventricular arrhythmia. Conclusion: The present case raises awareness by highlighting an unexplained and unexpected splenic infarction association with P-MAIVF as a result of infective endocarditis related to mixed bicuspid aortic valve disease.

Multimodality Imaging in the Evaluation of Ascending Aortic Pseudoaneurysms to Guide Complex Surgical Management

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Treatment of an AAP is surgical.

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The CorMatrix patch can lead to degradation and pseudoaneurysm formation.

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Use of multimodality imaging is key to evaluate, diagnose, and guide operation.

Infective Endocarditis Complicated by Pseudoaneurysm of the Mitral-Aortic Intervalvular Fibrosa Without Valvular Involvement

A pseudoaneurysm of the mitral-aortic intervalvular fibrosa (p-MAIVF) can be a catastrophic sequela of untreated active infective endocarditis. We describe a case of infective endocarditis complicated by p-MAIVF without valvular involvement. This case highlights the importance of this rare clinical entity and of transesophageal echocardiography in reaching a diagnosis. (Level of Difficulty: Beginner.)

Pseudoaneurysm of the Mitral-Aortic Fibrosa in the Absence of Valvulitis

The mitral-aortic intervalvular fibrosa (MAIVF) is the thin avascular fibrous structure located between the left side of the non-coronary cusp, the left coronary cusp and the anterior mitral leaflet. MAIVF pseudoaneurysm typically results as a complication of endocarditis, aortic valve surgery or chest trauma. We present a case of an incidental MAIF pseudoaneurysm in a 68-year female with a history of rheumatic fever without involvement of the mitral apparatus. We also discuss the presentation, evaluation and management of this rather rare valvular disorder.

Endovascular Closure of 2 Subannular Pseudoaneurysms of the Aortic Root After Surgical Aortic Valve Replacement

A 68-year-old woman was initially admitted with 2 subannular pseudoaneurysms of the aortic root after aortic valve replacement. The aneurysm expanded after 10 days and was treated using endovascular closure devices. (Level of Difficulty: Advanced.)

Aortomitral intervalvular fibrosa aneurysm-a rare case

Aortomitral intervalvular fibrosa aneurysm is a rare entity but a life-threatening condition. We present a case of young male presented with NYHA functional class IV dyspnea where aneurysm ruptured into the left atrium.

Unruptured Pseudoaneurysm of the Mitral Aortic Intervalvular Fibrosa

A 38-year-old female with a history of primary mitral regurgitation experienced shortness of breath even at rest 4 months previously. Cardiac computed tomography showed a large unruptured aneurysm arising from the mitral-aortic intervalvular fibrosa adjacent to the anterior mitral leaflet. The patient passed away because the pseudoaneurysm ruptured into the pericardium. (Level of Difficulty: Beginner.)

The transverse and oblique sinuses of the pericardium: Anatomic and echocardiographic insights

A number of masses and pseudomasses may be encountered during the echocardiographic examination of the transverse and oblique sinuses with significant clinical implications. This review discusses the clinically relevant anatomy of the pericardial sinuses emphasizing diagnostic pitfalls that may be encountered during their echocardiographic examination.

Pseudoaneurysm of the Mitral-Aortic Intervalvular Fibrosa: A Case Series with Literature Review

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P-MAIVF is usually a complication of endocarditis or aortic valve surgery.

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It is promptly recognized on transesophageal echocardiography.

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It may cause symptoms and complications that warrant surgical intervention.

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Surgical intervention remains the recommended management for P-MAIVF.

Congenital pseudoaneurysm of the mitral-aortic intervalvular fibrosa: a case report

The mitral-aortic intervalvular fibrosa is an area of fibrous continuity between the mitral and aortic valves. We present the first case of a congenital pseudoaneurysm in this region, detected prenatally as an isolated cardiac defect, which was followed-up conservatively postnatally. The diagnosis was confirmed by echocardiogram demonstrating blood flow into the pouch during systole and into the left ventricular outflow tract during diastole. The infant has been followed-up with serial echocardiograms demonstrating stable size and appearance of the lesion, without signs of obstruction, making close continued observation a reasonable approach.

Coil embolization of left ventricular outflow tract pseudoaneurysms: techniques and 5-year results

We present 3 cases of percutaneous coil embolization of left ventricular outflow tract (LVOT) pseudoaneurysms. All patients had a history of repetitive aortic root surgery and/or inflammatory disease. Computed tomography showed pseudoaneurysms connecting the sacs to the LVOT lumen. In each case, a 6-Fr catheter was advanced to the sac by the transfemoral approach. A 0.052-in coil was placed across the tract. There was no significant complications associated with the procedure. No recurrence was evident in any case during the 5-year follow-up. Coil embolization may be an effective treatment for these pseudoaneurysms in patients with complicated histories of aortic root surgery.

Congenital pseudoaneurysm of mitral-aortic intervalvular fibrosa masquerading as left atrial mass in fetal life

A 28-week-old fetus was detected to have a single left atrial mass in prenatal ultrasound. Postnatal echocardiography showed an aneurysm between the anterior mitral leaflet and aortic valve, to the left of atrioventricular junction and communicating with the left ventricle through a narrow mouth. It probably originated from the mitral-aortic intervalvular fibrous tissue and an inherent weakness at this site might be the cause. Reported cases of pseudoaneurysm of mitral-aortic intervalvular fibrosa and subvalvular ventricular aneurysms seen following infective endocarditis, surgery, or trauma seem to have a similar anatomical background. This case explains the possibility of congenital aneurysm in this location which needs to be considered a differential diagnosis in similar cases.

Cardiac Pseudoaneurysm- A Death Defying Entity

A pseudoaneurysm refers to a contained rupture of the myocardium with a tenuous pericardium walling off the leak. It needs to be differentiated from a true aneurysm by the fact that there is lack of myocardial tissue in the wall of a pseudoaneurysm. The differentiation between the two is pertinent as true aneurysms can be treated medically while pseudoaneurysms require urgent surgical treatment. Untreated pseudoaneurysms carry a high risk of rupture and mortality. We report a case of cardiac pseudoaneurysm developing in a 46-year-old male who had suffered myocardial infarction four months back. The patient now presented with chest pain and dyspnoea. CECT chest revealed a partially thrombosed large pseudoaneurysm arising from the posterior wall of left ventricle. While the clinical diagnosis of this entity is difficult, CECT plays a pivotal role in the non-invasive detection of pseudoaneurysms.