Pseudoaneurysm of the mitral-aortic intervalvular fibrosa

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.

Fistula of the mitral-aortic intervalvular fibrosa in a patient with bacterial endocarditis: a case report and systematic literature review

BACKGROUND

A fistulous tract in the mitro-aortic intervalvular fibrosa (MAIVF) is a rare entity, which presents as a complication of endocarditis or surgical trauma. Generally, it is associated to a pseudoaneurysm of the MAIVF (p-MAIVF) or aortic abscesses. MAIVF fistulas could potentially lead to devastating complications and a high mortality rate. This condition is managed surgically, either by a percutaneous closure or an open surgical approach. Herein we report the complex case of a patient with a MAIVF fistula secondary to bacterial endocarditis. Further clinical deterioration was caused by severe aortic valve insufficiency and hemodynamic compromise, requiring surgical intervention.

CASE PRESENTATION

A 74-year-old male patient was admitted to a primary care center with complaints of malaise, asthenia, adynamia, hyporexia, and lower limb edema over the past eight days. His past medical history is positive for arterial hypertension and being monorenal. A transesophageal echocardiogram (TEE) was performed, exhibiting a 56% left ventricle ejection fraction (LVEF) and complicated aortic valve endocarditis. Surgical management through an open approach included vegetation resection, valve replacement, and closure of the MAIVF fistula. After completing antibiotic therapy, the patient was discharged without complications. During postoperative follow-up, the patient remained asymptomatic, and the control echocardiogram showed no signs of MAIVF fistula.4.

CONCLUSIONS

The clinical case of a patient with a MAIVF fistula secondary to endocarditis by Streptococcus Anginous was presented. The fistulous tract was not associated to p-MAIVF or aortic abscess, findings which further deteriorate the patient's condition and increase the likelihood of fatality. This case reinforces the importance of a prompt diagnosis through cardiac imaging and timely surgical closure of the defect.

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 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.

Case report: Aorto-left atrial fistula-A rare complication of native aortic valve endocarditis

BACKGROUND

Aorto-cavitary fistula is a rare complication of infective endocarditis. Multimodal imaging is commonly required to assess the severity and extent of infection because of the complex pathology of the valvular and paravalvular apparatus in endocarditis.

CASE PRESENTATION

We present an unusual case of a middle-aged man with recent history of meningoencephalitis who developed infective endocarditis complicated by ruptured abscess in inter-valvular fibrosa between aortic and mitral valve resulting in free communication or fistula formation between aorta and left atrium. Patient underwent double valve replacement (aortic and mitral) along with repair of the aorta.

CONCLUSIONS

Our case highlights recognition of this rare clinical presentation of aorto-left atrial fistula in infective endocarditis and the diagnostic role of transesophageal echocardiography in good clinical outcome with aggressive and timely management.

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.

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.

A case of pseudoaneurysm of the mitral-aortic intervalvular fibrosa in a pediatric patient

Pseudoaneurysm of the mitral-aortic intervalvular fibrosa is a rare and potentially deadly aberrance of the cardiac architecture, with few reported pediatric cases. Complications can include rupture into the pericardium, ongoing infective endocarditis, arrhythmias, valvular dysfunction, thrombus formation, and compression of the coronary arteries. Although there have been cases which have gone solely with surveillance, the majority of these cases will have surgical intervention to reduce the risk of complications. We present a case in a pediatric patient with a history of bicuspid aortic valve, who presented with recurrent fevers after a dental procedure despite treatment with antibiotics. Infective endocarditis was suspected based on clinical exam, and imaging revealed pseudoaneurysm of the mitral-aortic intervalvular fibrosa. The patient was treated with surgical resection and homograft replacement.

Active infective endocarditis of a bicuspid aortic valve causing left ventricular outflow tract pseudoaneurysm and right atrium shunt: A case report

Introduction and importance

Left ventricular outflow tract pseudoaneurysm associated with infective endocarditis is a rare but life-threatening condition.

Case presentation

A 68-year-old man developed infective endocarditis of a bicuspid aortic valve with suspected annulus abscess and was transferred to our department for further treatment. Cardiac workup revealed the formation of a left ventricular outflow tract pseudoaneurysm penetrating the right atrium. We successfully treated the patient with pseudoaneurysm repair using a bovine pericardium patch in combination with aortic valve replacement. The patient was uneventfully discharged after 6-week antibiotic therapy and remained well for the following 2 years.

Clinical discussion

Surgery is the recommended treatment for left ventricular outflow tract pseudoaneurysms. Accurate diagnosis and identification of the anatomical conditions are crucial for determining the appropriate treatment.

Conclusion

When considering the appropriate surgical treatment for left ventricular outflow tract pseudoaneurysm associated with infective endocarditis, pseudoaneurysm repair using a bovine pericardial patch and concomitant aortic valve replacement can be an effective and feasible therapeutic option.

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Infective endocarditis can cause left ventricular outflow tract pseudoaneurysms.

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Surgery is recommended for left ventricular outflow tract pseudoaneurysms.

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Accurate anatomical diagnosis is crucial for determining the appropriate treatment.

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.

Delayed patch repair of a ruptured mitral subvalvular pseudoaneurysm caused by infective endocarditis: a case report

Background

Ruptured subvalvular pseudoaneurysm is a rare but significantly fatal complication of infective endocarditis. We report a successful surgical case of ruptured subvalvular pseudoaneurysm with infective endocarditis.

Case summary

A 46-year-old man presenting with high fever was admitted to a local hospital. Physical examination revealed small erythema and petechiae on his lower limbs. Transthoracic echocardiogram did not show any visible vegetation and valvular disease; however, magnetic resonance imaging (MRI) showed multiple acute cerebral infractions, and methicillin-susceptible Staphylococcus aureus was detected in the blood culture. Infective endocarditis was suspected, and an antibacterial medication was initiated. Twelve days later, he suffered from a sudden cardiogenic shock due to cardiac tamponade. Bloody pericardial effusion (1600 mL) was drained, and his condition improved substantially. Transoesophageal echocardiography after pericardial drainage revealed severe mitral regurgitation and a subvalvular aneurysm at the posteromedial side of the mitral annulus; these were not detected at the time of admission. He was transferred to our hospital for surgery; however, since fresh cerebral bleeding was observed in MRI, the surgery was delayed. Three weeks later, after confirming that the blood culture was negative for any growth, patch repair of the subvalvular pseudoaneurysm and mitral valve repair were performed. Post-operatively, no complication or arrhythmia was observed; he was discharged 25 days later.

Discussion

We report a rare case of successful delayed surgery for a ruptured subvalvular pseudoaneurysm at the posteromedial side of the mitral annulus, which presented complications for infective endocarditis by S. aureus.

Pseudoaneurysm of the mitral-aortic intervalvular fibrosa following endocarditis and aortic valve surgery in an infant-Case report and exhaustive systematic review of pediatric cases

Pseudoaneurysm of the mitral-aortic intervalvular fibrosa (P-MAIVF) continues to be a rare diagnosis in children. Etiology, presentation, and management strategies are considerably different from adults. We report a fatal case of P-MAIVF with classical transthoracic and transesophageal echocardiographic findings complemented by CT imaging. The natural course of uncomplicated/asymptomatic P-MAIVF is largely unknown since most patients are offered surgery. We present an extensive literature review of pediatric P-MAIVF and highlight important differences from the adult form of this disease.

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.

Fistula formation following repair of a pseudoaneurysm of the mitral-aortic intervalvular fibrosa - A rare complication

The mitral-aortic intervalvular fibrosa is an avascular fibrous structure connecting the mitral and aortic annuli that is prone to pseudoaneurysm formation. Pseudoaneurysm of the mitral-aortic intervalvular fibrosa is a known complication of many conditions such as infective endocarditis and valvular surgery. It requires surgical correction. Its long-term consequences are little known. We present in this report the case of a 62-year-old male with history of pseudoaneurysm of the mitral-aortic intervalvular fibrosa repair and redo mitral and aortic prosthetic valve replacements. After five years of asymptomatic follow-up, the patient presented with sudden-onset heart failure. Echocardiographic investigation demonstrated two aorto-atrial fistulae at the site of his previous repair and adequate function of both prosthetic valves. The fistulae were repaired and the prosthetic valves were left in place. This represents a potential late surgical complication of pseudoaneurysm of the mitral-aortic intervalvular fibrosa. <Learning Objectives: This case report describes a rare complication occurring many years after the repair of a pseudoaneurysm of the mitral-aortic intervalvular fibrosa. Surgical and follow-up history is discussed to familiarize clinicians with this atypical presentation type.>.

Septic Shock of Unknown Origin: A Case Report of a Pseudoaneurysm of the Mitral-Aortic Intervalvular Fibrosa

Pseudoaneurysm of the mitral-aortic intervalvular fibrosa (P-MAIVF) is a rare complication of infective endocarditis and trauma, particularly of aortic valve surgery. Clinical symptoms are usually unspecific and generally due to complications. Transesophageal echocardiography (TEE) is the most commonly used exam to diagnose P-MAIVF. The main echocardiographic feature is the presence of a cavity communicating with the left ventricular outflow tract that expands during systole and collapses during diastole. Most frequent complications are formation of a fistulous tract and compression of adjacent structures. Surgical correction is usually the treatment of choice. The authors describe a case of a female patient with a septic shock of unclear origin. After antibiotic therapy and organ-supporting measures without apparent improvements, a TEE revealed infective endocarditis, complicated with P-MAIVF. Despite adequate treatment, the patient did not survive for long enough to be submitted to surgical repair.

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.

Organizing Thrombus Mimicking a Cardiac Tumor Located at the Mitral-Aortic Intervalvular Fibrosa

Thrombosis at the left ventricular outflow tract occurs without any detectable heart disease or predisposing factors only extremely rarely. A 48-year-old male visited Konkuk University Medical Center with loss of consciousness one month prior to presentation. Before he visited our hospital, he had been diagnosed with a cardiac tumor, which was located between the left atrium and posterior aortic root, and which was adjacent to both the aortic and mitral valves. Cardiac transplantation was recommended at the other hospital because of the high risk of cardiac dysfunction induced by both aortic and mitral valvular dysfunction after surgical resection. Based on preoperative transthoracic echocardiography, cardiac computed tomography, cardiac magnetic resonance imaging, and intra-operative transesophageal echocardiography, we considered it to be a benign tumor. Complete resection was achieved and the pathology confirmed organizing thrombus. We report a case of organizing thrombus mimicking a cardiac tumor, which was located at the mitral-aortic intervalvular fibrosa of the left ventricular outflow tract without any heart disease.

Infective Endocarditis with Intermittent Atrioventricular Block and Pseudoaneurysm of the Mitral-aortic Intervalvular Fibrosa in a Patient with Severe Aortic Stenosis

Atrioventricular (AV) block and pseudoaneurysm of the mitral-aortic intervalvular fibrosa (P-MAIVF) are rare complications of infective endocarditis (IE). A 72-year-old man with severe aortic stenosis was hospitalized due to IE. After admission, intermittent AV block and P-MAIVF were noted. Interestingly, an accelerated junctional rhythm was observed during the process of AV block resolution. Elective surgery, which included patch closure of the fistula and replacement of the aortic valve, was successfully performed. The patient has remained in good condition without the recurrence of AV block. This case report describes a rare comorbidity of AV block and P-MAIVF in a patient with aortic valve IE.

Infective Endocarditis Presenting as Acute Renal Failure and Unusual Complications

Infective endocarditis can be a diagnostic challenge. Few cases have so far reported infective endocarditis presenting as renal failure. Pseudoaneurysms of the mitral-aortic intervalvular fibrosa and splenic abscess are rare complications of infective endocarditis. We herein report a case of an 80-year-old man admitted due to anorexia, malaise, edema of the legs and renal failure. A progressive degradation of the patient's renal function was documented and hemodialysis was started. Blood cultures revealed the presence of Enterococcus faecalis, and the patient was treated with ampicillin and gentamicin. The transesophageal echocardiogram findings showed pseudoaneurysms of the mitral-aortic intervalvular fibrosa and in the aortic root wall. Due to abdominal pain, an abdominal CT scan was performed and showed a cystic lesion compatible with splenic abscess. The patient received 6 weeks of antibiotic treatment. There was progressive clinical improvement and regression of the splenic abscess, but no recovery of the renal function. This report illustrates an unusual clinical presentation of infective endocarditis with unusual complications that were successfully treated with antibiotics.

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

Pseudoaneurysm of the mitral-aortic intervalvular fibrosa (P-MAIVF) is an infrequent but potentially life-threatening condition. Both transthoracic echocardiography (TTE) and transesophageal echocardiography (TEE) can detect P-MAIVF with sensitivity rates of 43 and 90 %, respectively. The typical finding of echocardiography is a pulsatile echo-free sac that expands in systole and collapses in diastole. Our review comprises 166 patients with P-MAIVF, including eight cases in our hospital and 158 cases from the literature. P-MAIVF is often associated with infection or surgical trauma. While it is likely to maintain an asymptomatic course, symptoms of shortness of breath, heart failure, valvular disease, chest pain, endocarditis, and cerebrovascular events are common clinical presentations. The recommended treatment is surgery. However, conservative therapy is an alternative approach for high-risk patients or when surgical treatment is refused. With the increasing incidence of cardiac surgery and infective endocarditis, a likely increment in the new diagnosis of pseudoaneurysm is expected.

Mitro-aortic aneurysms in children: single-centre experience and review of the literature

OBJECTIVES

This publication aims to report the cases of four children with pseudoaneurysm of the mitral-aortic intervalvular fibrosa and carry out a review of the literature.

BACKGROUND

Pseudoaneurysm of the mitral-aortic intervalvular fibrosa is a very rare anomaly in children. It can be either congenital or acquired, namely, after bacterial endocarditis or cardiac trauma. This pathology does not usually cause specific symptoms but its outcome may be potentially fatal.

METHODS

We report the cases of four patients presenting with pseudoaneurysm of the mitral-aortic intervalvular fibrosa, referred for treatment in a paediatric cardiology clinic. Patient clinical notes were retrospectively reviewed for aetiology, clinical presentation, diagnostic work-up, surgical treatment, and follow-up. Literature on the subject was extensively reviewed.

RESULTS

In three patients, pseudoaneurysm of the mitral-aortic intervalvular fibrosa was acquired, being secondary to bacterial endocarditis in two cases and establishing after mitral surgery in another case. The remaining patient had a "congenital" aetiology - no other cause could be traced. The diagnosis was achieved by transthoracic echocardiography for all patients, and confirmed in all by trans-oesophageal echocardiography, to better define morphological details and to access flow into the aneurysmal formation. All patients were submitted to corrective cardiac surgery. Of the patients, three survived and were cured by surgery, staying asymptomatic, and one died after repeated interventions, for persistent endocarditis.

CONCLUSIONS

Pseudoaneurysm of the mitral-aortic intervalvular fibrosa is a rare but potentially fatal anomaly. In our experience, surgical cure was achieved for the majority of the cases, except for a case for which infection could not be locally eradicated, leading to multiple reinterventions.

Subacute Staphylococcus epidermidis Bacterial Endocarditis Complicated by Mitral-Aortic Intervalvular Fibrosa Pseudoaneurysm

The patient is a 75-year-old man with a history significant for hypertension and congestive heart failure who underwent a bioprosthetic aortic valve replacement secondary to acute onset of aortic insufficiency. Cultures of the native valve were positive for Staphylococcus epidermidis sensitive to nafcillin and intravenous cefazolin was initiated. On postoperative day 24, he developed acute decompensated heart failure. A transesophageal echocardiogram demonstrated a structurally abnormal mitral valve with severe regurgitation, anterior and posterior leaflet vegetations, and scallop prolapse. There was also evidence of a mitral-aortic intervalvular fibrosa pseudoaneurysm (P-MAIF) with systolic expansion and flow within the aneurysm. Antibiotic treatment was changed from cefazolin to vancomycin for presumed development of methicillin-resistant Staphylococcus. He subsequently underwent a bioprosthetic mitral valve replacement and has restoration of health without sequella. This case highlights the development of a P-MAIF as a rare complication of both aortic or mitral valve replacement and infective endocarditis.