Left ventricular pseudoaneurysm after mitral valve replacement

Recurrence of left ventricular pseudoaneurysm after multiple mitral valve replacements

Left ventricular pseudoaneurysm (LVPA) formation is a potentially lethal complication of myocardial infarction (MI] and mitral valve (MV) replacement that requires prompt diagnosis and treatment. A female patient who had been complaining of exertional dyspnea underwent a two-dimensional transthoracic echocardiogram (TTE) which revealed a functioning mechanical MV with severe paravalvular leak, severe tricuspid regurgitation (TR) and severely elevated pulmonary artery systolic pressure. Moreover, echo-lucent space at the postero-lateral portion of the left ventricle near the MV was seen, suggestive of a large LVPA. Transesophageal echocardiography (TEE) and Computed Tomography (CT) angiography confirmed these findings. Afterwards, the patient had a surgical repair for the LVPA along with mitral and tricuspid valve (TV) replacement. Three months later, the patient presented with symptoms of congestive heart failure. The LVPA had recurred at the same location of the previous pseudoaneurysm and given the high risk for reoperating on the patient, close monitoring and medical management was deemed as a better option.

Prevalence and extent of mitral annular disjunction in structurally normal hearts: comprehensive 3D analysis using cardiac computed tomography

AIMS

Mitral annular disjunction is fibrous separation between the attachment of the posterior mitral leaflet and the basal left ventricular myocardium initially described in dissected hearts. Currently, it is commonly evaluated by echocardiography, and potential relationships with mitral valve prolapse and ventricular arrhythmia have been suggested. However, controversy remains as its prevalence and extent have not been fully elucidated in normal living subjects.

METHODS AND RESULTS

Systolic datasets of cardiac computed tomography obtained from 98 patients (mean age, 69.1 ± 12.6 years; 81% men) with structurally normal hearts were assessed retrospectively. Circumferential extent of both mitral leaflets and disjunction was determined by rotating orthogonal multiplanar reconstruction images around the central axis of the mitral valvar orifice. Distribution angle within the circumference of the mitral valvar attachment and maximal height of disjunction were quantified. In total, 96.0% of patients demonstrated disjunction. Average distribution angles of the anterior and posterior mitral leaflets were 91.3 ± 9.4° and 269.8 ± 9.7°, respectively. Average distribution angle of the disjunction was 105.1 ± 49.2°, corresponding to 39.0 ± 18.2% of the entire posterior mitral valvar attachment. Median value of the maximal height of disjunction was 3.0 (1.5-7.0) mm. Distribution prevalence map of the disjunction revealed characteristic double peaks, with frequent sites of the disjunction located at the anterior to antero-lateral and inferior to infero-septal regions.

CONCLUSION

Mitral annular disjunction is a rather common finding in the normal adult heart with bimodal distribution predominantly observed involving the P1 and P3 scallops of the posterior mitral leaflet.

Late atrioventricular groove disruption presenting 7 years after mitral valve replacement: a case report

Background

Left ventricular rupture is the most feared complication in mitral valve surgery. Despite its low incidence, mortality rates can reach up to 75%. It usually presents on the operating room with a dissecting haematoma followed by massive bleeding after discontinuing cardiopulmomary bypass. However, cardiac rupture may be contained by adherent pericardium or scar tissue leading to chronic formation of a pseudoaneurysm (PSA).

Case summary

A 44-year-old man came to our institution with acute heart failure triggered by community-acquired pneumonia. He underwent mitral valve replacement with a mechanical prosthesis 7 years before and reported suffering from chronic worsening dyspnoea for 18 months. He underwent chest computed tomography scan and cardiac magnetic resonance imaging (CMRI), which showed two extensive left ventricular (LV) multilobulated PSAs. An operative approach was chosen and a tear was found on the posterior atrioventricular groove (AVG), communicating left ventricle with the PSA, which was closed with bovine pericardium patch. After weaning from cardiopulmonary bypass, he presented a diffuse life-threatening bleeding. The surgeons packed his chest with compresses before closing the sternum and he was operatively revised after 48 h. Post-operative CMRI showed that one of the PSAs remained connected with the LV. Despite of all, 1 year after hospital discharge, he remains asymptomatic without signs of heart failure.

Discussion

This case illustrates PSAs' potential to grow for a long period before causing symptoms, the complexity and risks of chronic AVG disruption surgery and the importance of careful annular manipulation and debridement as preventive measures in mitral valve surgery.