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An aneurysm of posterior mitral valve mimicking a huge vegetation
International Journal of Cardiology 107 (2006) 277 – 278 www.elsevier.com/locate/ijcard
Letter to the Editor
An aneurysm of posterior mitral valve mimicking a huge vegetation Cheng-Han Lee, Liang-Miin Tsai* Division of Cardiology, Department of Internal Medicine, Cheng Kung University Hospital, Tainan, Taiwan Received 10 January 2005; accepted 19 January 2005 Available online 25 April 2005
Keywords: Infective endocarditis; Mitral valve aneurysm
1. Case report A 59-year-old man was admitted for treatment of intermittent fever and progressive shortness of breath for about 1 week. Orthopnea and edema of lower legs were noted. On admission, the jugular vein was distended up to 7 cm above the sternal angle. Crackles were heard over both lower lungs. A grade 3/6 pansystolic murmur over precordial area and apex was heard. Transthoracic echocardiography demonstrated a redundant, thickened and prolapsed leaflet of the posterior mitral valve with moderate to severe eccentric mitral regurgitation. A fluttering mass echo was observed on posterior leaflet of the mitral valve (Fig. 1). Two days later, two sets of blood culture both disclosed gram negative bacilli. Abdominal and chest computed tomography did not identify origins of infection. Transesophageal echocardiography (Fig. 2) demonstrated a calcified aneurysm of posterior mitral leaflet which resulted in poor coaptation of mitral valve. The color Doppler flow showed that the aneurysm was filled with flow during systole and no communication with left atrium. Moderate to severe eccentrically anterior mitral regurgitation was also identified. Furthermore, we could see a small vegetation on posterior mitral leaflet. No vegetations were viewed on aortic valve. Blood cultures were positive for Salmonella species. Antibiotics had been given for 4 weeks. Mitral valve replacement was recommended for fear of rupture of the aneurysm and deterioration of mitral regurgitation,
* Corresponding author. Department of Medicine, School of Medicine, National Cheng Kung University Hospital, 138 Sheng-Li Road, Tainan 704, Taiwan. Tel.: +886 6 235 3535x2389; fax: +886 6 275 3834. E-mail address: [email protected] (L.-M. Tsai). 0167-5273/$ - see front matter D 2005 Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.ijcard.2005.01.066
but refused by the patient. He received medications for relief of congestive heart failure and was discharged with stable condition.
2. Discussion Aneurysm of the leaflet of the mitral valve is rarely encountered. It usually occurs as an early or late complication of aortic valve endocarditis because infection spreads to the mitral valve. According to previous reports, the location of aneurysmal mitral leaflet was always on the anterior mitral leaflet due to the direction of the aortic regurgitant jet [1]. The major complication of the mitral valve aneurysm is rupture of aneurysmal cavity into left atrium. Therefore, some authors recom-
Fig. 1. Two-dimensional transthoracic echocardiography disclosed a large fluttering echo (arrow) on posterior mitral leaflet. LV denotes left ventricle; LA, left atrium; RA, right atrium; RV, right ventricle.
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C.-H. Lee, L.-M. Tsai / International Journal of Cardiology 107 (2006) 277 – 278
unknown whether the mitral aneurysm was preexisting or occurring secondary to infective endocarditis. Our case suggested that mitral aneurysm could happen on posterior leaflet of the mitral valve as complications of endocarditis without apparent involvement of the aortic valve. Second, the aneurysm was only clearly observed by TEE, indicating the superiority of TEE to TTE for identifying this rare mitral valve pathology especially on posterior mitral valve. A better sensitivity of TEE in detecting anterior mitral valve aneurysm was also previously reported [4]. In conclusion, TEE is a very useful tool for identifying mitral valve pathologies as complications of endocarditis when they occur rarely on posterior mitral leaflet. Fig. 2. The color Doppler imaging of TEE demonstrated the eccentric mitral regurgitant jet directing to the aneurysm of posterior mitral leaflet (arrow) and thereafter to anterior cavity of left atrium. LV denoted left ventricle; LA, left atrium.
mend prompt surgical repair for all infectious aneurysms of the mitral valve [2]. Others, however, consider that regular echocardiographic follow-up is enough if the aneurysm is intact and unchanging and if aortic regurgitation is mild [3]. Our case was unique on several grounds. First, aneurysmal formation of mitral leaflets happened on posterior mitral leaflet, but not on anterior leaflet. Until now, we can not find any report of infective endocarditis with mitral aneurysm involving the posterior leaflet. It is
References [1] Reid CL, Chandraratna AN, Herrison E, et al. Mitral valve aneurysm: clinical features, echocardiographic – pathologic correlations. J Am Coll Cardiol 1983;2:460 – 4. [2] Saiki Y, Kawase M, Ida T, et al. The successful surgical repair of a left ventricular – right atrial communication and aneurysm of the mitral valve caused by infective endocarditis: report of a case. Surg Today 1994;24:655 – 8. [3] Prian GW, Diethrich EB. Sinus of Valsalva abnormalities: a specific differentiation between aneurysms of and aneurysms involving the sinus of Valsalva. Vasc Surg 1973;7:155 – 64. [4] Cziner DG, Rosenzweig BP, Katz ES, Keller Am, Daniel WG, Kronzon I. Transesophageal versus transthoracic echocardiography for diagnosing mitral valve perforation. Am J Cardiol 1992;69:1495.
Letter to the Editor
An aneurysm of posterior mitral valve mimicking a huge vegetation Cheng-Han Lee, Liang-Miin Tsai* Division of Cardiology, Department of Internal Medicine, Cheng Kung University Hospital, Tainan, Taiwan Received 10 January 2005; accepted 19 January 2005 Available online 25 April 2005
Keywords: Infective endocarditis; Mitral valve aneurysm
1. Case report A 59-year-old man was admitted for treatment of intermittent fever and progressive shortness of breath for about 1 week. Orthopnea and edema of lower legs were noted. On admission, the jugular vein was distended up to 7 cm above the sternal angle. Crackles were heard over both lower lungs. A grade 3/6 pansystolic murmur over precordial area and apex was heard. Transthoracic echocardiography demonstrated a redundant, thickened and prolapsed leaflet of the posterior mitral valve with moderate to severe eccentric mitral regurgitation. A fluttering mass echo was observed on posterior leaflet of the mitral valve (Fig. 1). Two days later, two sets of blood culture both disclosed gram negative bacilli. Abdominal and chest computed tomography did not identify origins of infection. Transesophageal echocardiography (Fig. 2) demonstrated a calcified aneurysm of posterior mitral leaflet which resulted in poor coaptation of mitral valve. The color Doppler flow showed that the aneurysm was filled with flow during systole and no communication with left atrium. Moderate to severe eccentrically anterior mitral regurgitation was also identified. Furthermore, we could see a small vegetation on posterior mitral leaflet. No vegetations were viewed on aortic valve. Blood cultures were positive for Salmonella species. Antibiotics had been given for 4 weeks. Mitral valve replacement was recommended for fear of rupture of the aneurysm and deterioration of mitral regurgitation,
* Corresponding author. Department of Medicine, School of Medicine, National Cheng Kung University Hospital, 138 Sheng-Li Road, Tainan 704, Taiwan. Tel.: +886 6 235 3535x2389; fax: +886 6 275 3834. E-mail address: [email protected] (L.-M. Tsai). 0167-5273/$ - see front matter D 2005 Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.ijcard.2005.01.066
but refused by the patient. He received medications for relief of congestive heart failure and was discharged with stable condition.
2. Discussion Aneurysm of the leaflet of the mitral valve is rarely encountered. It usually occurs as an early or late complication of aortic valve endocarditis because infection spreads to the mitral valve. According to previous reports, the location of aneurysmal mitral leaflet was always on the anterior mitral leaflet due to the direction of the aortic regurgitant jet [1]. The major complication of the mitral valve aneurysm is rupture of aneurysmal cavity into left atrium. Therefore, some authors recom-
Fig. 1. Two-dimensional transthoracic echocardiography disclosed a large fluttering echo (arrow) on posterior mitral leaflet. LV denotes left ventricle; LA, left atrium; RA, right atrium; RV, right ventricle.
278
C.-H. Lee, L.-M. Tsai / International Journal of Cardiology 107 (2006) 277 – 278
unknown whether the mitral aneurysm was preexisting or occurring secondary to infective endocarditis. Our case suggested that mitral aneurysm could happen on posterior leaflet of the mitral valve as complications of endocarditis without apparent involvement of the aortic valve. Second, the aneurysm was only clearly observed by TEE, indicating the superiority of TEE to TTE for identifying this rare mitral valve pathology especially on posterior mitral valve. A better sensitivity of TEE in detecting anterior mitral valve aneurysm was also previously reported [4]. In conclusion, TEE is a very useful tool for identifying mitral valve pathologies as complications of endocarditis when they occur rarely on posterior mitral leaflet. Fig. 2. The color Doppler imaging of TEE demonstrated the eccentric mitral regurgitant jet directing to the aneurysm of posterior mitral leaflet (arrow) and thereafter to anterior cavity of left atrium. LV denoted left ventricle; LA, left atrium.
mend prompt surgical repair for all infectious aneurysms of the mitral valve [2]. Others, however, consider that regular echocardiographic follow-up is enough if the aneurysm is intact and unchanging and if aortic regurgitation is mild [3]. Our case was unique on several grounds. First, aneurysmal formation of mitral leaflets happened on posterior mitral leaflet, but not on anterior leaflet. Until now, we can not find any report of infective endocarditis with mitral aneurysm involving the posterior leaflet. It is
References [1] Reid CL, Chandraratna AN, Herrison E, et al. Mitral valve aneurysm: clinical features, echocardiographic – pathologic correlations. J Am Coll Cardiol 1983;2:460 – 4. [2] Saiki Y, Kawase M, Ida T, et al. The successful surgical repair of a left ventricular – right atrial communication and aneurysm of the mitral valve caused by infective endocarditis: report of a case. Surg Today 1994;24:655 – 8. [3] Prian GW, Diethrich EB. Sinus of Valsalva abnormalities: a specific differentiation between aneurysms of and aneurysms involving the sinus of Valsalva. Vasc Surg 1973;7:155 – 64. [4] Cziner DG, Rosenzweig BP, Katz ES, Keller Am, Daniel WG, Kronzon I. Transesophageal versus transthoracic echocardiography for diagnosing mitral valve perforation. Am J Cardiol 1992;69:1495.