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False aneurysm of mitral-aortic intervalvular fibrosa: Diagnosis by 2-dimensional contrast echocardiography at cardiac catheterization
June 1983
THE AMERICAN JOURNAL OF CARDIOLOGY
Volume 51
1801
False Aneurysm of Mitral-Aortic lntervalvularFibrosa:Diagnosisby 2-DimensionalContrast Echocardiographyat Cardiac Catheterization Cheryl L. Reid, MD Charles McKay, MD David T. Kawanishi, MD Charles Edwards, MD Shahbudin H. Rahimtoola, MB, FRCP P. Anthony N. Chandraratna, MD, MRCP
aneurysm of the mitral-aortic intervalvular fibrosa may occur as a complication of aortic valve infective end0carditis.l These aneurysms may rupture causing death, may develop thrombi that may embolize, and may cause detachment of the aortic or mitral valve.1>2 Accurate and early diagnosis is important for successful surgical therapy. We describe a patient in whom the diagnosis was made before surgery by contrast 2-dimensional(2-D) echocardiography.
Al
False
FIGURE 1. Parasternal long-axis view shows the aneurysmal sac (An) as an echo-free space between the posterior aortic wall (Ao) and the left atrium (LA). The aneurysm appears to increase in size during systole (upper panel) and to decrease in size during diastole (lower panel) as shown by the simultaneously recorded electrocardiogram. A large aortic valve vegetation (V) prolapses into the left ventricle (LV) during diistole (lower panel). The anterior leaflet of the mitral valve (MV) has an abnormal bulge at the base present during diastole (lower panel). IVS = interventricular septum.
A 28-year-old man had symptoms of night sweats for 6 weeks. Aortic systolic ejection and early diastolic murmurs (both grade 316) were heard; an Ss gallop was present. Blood culturesgrew group D enterococcus; he was treated with intravenous ampicillin and gentamicin. On 2-D echocardiography, a large aortic valve vegetation was seen prolapsing into the left ventricle. A large aneurysmal sac was present between the posterior aortic wall and the left atrium, which expanded during systole (Fig. 1, upper panel) and decreased during diastole (Fig. 1, lower panel). The left ventricle was dilated. Peripheral venous 2-D contrast echocardiography was unremarkable. At catheterization, right heart pressure and blood oxygen saturation were within normal limits. The presence of severe aortic regurgitation was confirmed. Contrast 2-D echocardiography, performed through the intracardiac catheter, demonstrated that the aneurysmal sac filled from the left ventricle and not from the aorta, and no mitral regurgitation was seen (Fig. 2). The origin of the aneurysm, demonstrated by 2-D contrast echocardiography, was later confirmed by cineangiography. During surgery, the aortic valve was bicuspid and extensively destroyed by vegetation. The ostium of the false aneurysm measured 2 X 2 cm and was located beneath the aortic valve noncoronary cusp in the fibrous continuity between the mitral and aortic valves. The false aneurysm extended onto the superior aspect of the left atrium, ending in a blind pouch. The mitral valve was normal. The opening of the false aneurysm was closed and the aortic valve replaced with a bioprosthesis. Postoperative echocardiography showed the region of the aneurysm to be indistinct, probably because of thrombus formation. Contrast echocardiography performed through the left atria1
line showed no filling of the false aneurysm by the contrast material, confirming the security of the surgical closure.
From the Section of Cardiology, Department
of Medicine, and the of Cardiac Surgery, Department of Surgery, University of Southern California School of Medicine, Los Angeles, California. __ Manuscript received February 4, 1983; revised manuscript received and accepted March 7, 1983. Section
Aneurysms of the mitral-aortic intervalvular fibrosa are due to the spread of infection from the aortic valve. The intervalvular fibrosa attaches to the aortic root and to the anterior leaflet of the mitral valve. Perforation from infection in this area may cause an aneurysm to develop in the epicardial tissue between the aorta and
FlGUFlE 2. Contrast Zdimensional echocardiographic study (parasternal long-axis views) performed during cardiac catheterization with the catheter (C) positioned in the aortic root (upper panel). The left ventricle (LV) filled with contrast during the first diastolic interval after injection. The aneurysm (An) then filled with the first systole after injection (lower panel). No contrast material is seen in the left atrium (LA). IVS = interventricular septum; MV = mitral valve.
1802
BRIEF REPORTS
left atrium which is in direct communication with the pericardial space. Angiographic studies have been the standard method for detecting these aneurysms. However, precise definition of structures by angiography is difficult because the left ventricular outflow tract may be obscured by overlapping contrast-filled structures. In addition, the number of views is limited by the amount of contrast material that can be used in an individual patient. In our patient, contrast 2-D echocardiography was useful (1) to define that the aneurysm originated from the left side of the heart, (2) to demonstrate that the aneurysm filled from the left ventricle, and (3) to confirm obliteration of the aneurysm postoperatively. Two-dimensional echocardiography was particularly helpful because of the added spatial orientation. An echo-free space lying
between the posterior aortic root and the left atrium expanded during systole. Contrast 2-D echocardiography was then used to define its relation to the intracardiac chambers. Our case, the first to describe an aneurysm of the mitral-aortic intervalvular fibrosa by 2-D echocardiography, demonstrates the usefulness of contrast 2-D echocardiography during cardiac catheterization in defining this “complex” cardiac lesion. Acknowledgment: We acknowledge with gratitude the technical assistance of Michael Butler. References 1. Chesler E, KornsME, Porter GE, Reyes CN, Edwards JE. False aneurysm of the left ventricle secondaryto bacterial endocarditiswith perforationof the mitral-aorticintervalvularfibrosa.Circulation1966;37:516-523. 2. Gonzalez-LavinL, Scappatlna E, Llse M, RossDN. Mycoticaneurysmsof the aortic root:a complicationof aorticvalveendocarditis.Ann ThoracSurg 1970;9:551-561.
Platypnea and lnteratrial Right-to-Left Shunting After Lobectomy Robert M. Springer, MD Mihai Gheorghiade, MD C. Simon Chakko, MD George M. Bell, MD Richard 0. Cannon, III, MD Joann Urquhart, MD Michael Jones, MD Robert 0. Bonow, MD
is dyspnea in the upright position relieved in the supine position. This unusual symptom has been reported after pneumonectomy due to a new onset of right-to-left shunting through a previously unrecognized atria1 septal defect or a patent foramen ovale in the absence of pulmonary hypertension.1-5 Platypnea
A 63-year-old man presented with cough and hoarseness. X-ray disclosed a mass in the lower lobe of the right lung, and aspiration biopsy disclosed adenocarcinoma. Right lower lobectomy was performed. He was readmitted to the hospital 4 months later for dyspnea. Electrocardiography revealed sinus tachycardia and nonspecific ST-T changes. At pulmonary angiography which was negative for emboli, the 7F pigtail catheter slipped repeatedly into the left atrium. It was apparent that the patient was dyspneic and cyanotic only when erect and was comfortable in the supine position. Arterial blood gases on 40% oxygen were: pH 7.42, partial pressure of carbon dioxide 29 mm Hg, partial pressure of oxygen 81 mm Hg in the supine position, and 7.44,25 mm Hg, and 44 mm Hg, respectively, in the upright position. On 100% oxygen, partial pressure of oxygen was 56 mm Hg. The
From the Section of Cardiology, Veterans Administration Medical Center, Salem, Virginia; University of Virginia, Charlottesville, Virginia; and Cardiology and Surgery Branches, National Heart, Lung, and Blood InStitUte, National institutes of Health, Bethesda, Maryland. Manuscript received February 16, 1983; revised manuscript received March 1, 1983, accepted March 4. 1983.
FIGURE 1. Contrast 2-dimensional echocardiogram, subcostal 4chamber view. The circles indicate contrast material appearing in all 4 chambers after injection into the superior vena cava. LA = left atrium; LV = left ventricle; RA = right atrium; RV = right ventricle.
TABLE I
Hemodynamics
Pressures (mm Hg) Right atrium (mean) Right ventricle Pulmonary artery Pulmonary artery wedge Oxygen saturations (%) Mixed venous Pulmonary artery Pulmonary vein Radial artery QsfQp
Supine
Sitting
4 2013 20110 10
2 1712 17/7 7
t: t: 2.1
diagnosis of right-to-left shunt was made conclusively by contrast echocardiography. Boluses of 10 ml of saline solution were injected into the right atrium. Contrast echoes appeared in all 4 cardiac chambers only when the patient was in the sitting position (Fig. 1). Right-sided cardiac catheterization was performed (Table I). Oxygen saturation measurements (Table I) revealed a significant right-to-left atria1 level shunt only in the upright position. The systemic-to-pulmonary flow ratio (QsIQp) was 2.1. Because the patient was confined to bed, being dyspneic and cyanotic only in the upright position, percutaneous closure of the defect was attempted using an umbrella prosthesis. The umbrella failed to fix to the atria1 septum and migrated into
THE AMERICAN JOURNAL OF CARDIOLOGY
Volume 51
1801
False Aneurysm of Mitral-Aortic lntervalvularFibrosa:Diagnosisby 2-DimensionalContrast Echocardiographyat Cardiac Catheterization Cheryl L. Reid, MD Charles McKay, MD David T. Kawanishi, MD Charles Edwards, MD Shahbudin H. Rahimtoola, MB, FRCP P. Anthony N. Chandraratna, MD, MRCP
aneurysm of the mitral-aortic intervalvular fibrosa may occur as a complication of aortic valve infective end0carditis.l These aneurysms may rupture causing death, may develop thrombi that may embolize, and may cause detachment of the aortic or mitral valve.1>2 Accurate and early diagnosis is important for successful surgical therapy. We describe a patient in whom the diagnosis was made before surgery by contrast 2-dimensional(2-D) echocardiography.
Al
False
FIGURE 1. Parasternal long-axis view shows the aneurysmal sac (An) as an echo-free space between the posterior aortic wall (Ao) and the left atrium (LA). The aneurysm appears to increase in size during systole (upper panel) and to decrease in size during diastole (lower panel) as shown by the simultaneously recorded electrocardiogram. A large aortic valve vegetation (V) prolapses into the left ventricle (LV) during diistole (lower panel). The anterior leaflet of the mitral valve (MV) has an abnormal bulge at the base present during diastole (lower panel). IVS = interventricular septum.
A 28-year-old man had symptoms of night sweats for 6 weeks. Aortic systolic ejection and early diastolic murmurs (both grade 316) were heard; an Ss gallop was present. Blood culturesgrew group D enterococcus; he was treated with intravenous ampicillin and gentamicin. On 2-D echocardiography, a large aortic valve vegetation was seen prolapsing into the left ventricle. A large aneurysmal sac was present between the posterior aortic wall and the left atrium, which expanded during systole (Fig. 1, upper panel) and decreased during diastole (Fig. 1, lower panel). The left ventricle was dilated. Peripheral venous 2-D contrast echocardiography was unremarkable. At catheterization, right heart pressure and blood oxygen saturation were within normal limits. The presence of severe aortic regurgitation was confirmed. Contrast 2-D echocardiography, performed through the intracardiac catheter, demonstrated that the aneurysmal sac filled from the left ventricle and not from the aorta, and no mitral regurgitation was seen (Fig. 2). The origin of the aneurysm, demonstrated by 2-D contrast echocardiography, was later confirmed by cineangiography. During surgery, the aortic valve was bicuspid and extensively destroyed by vegetation. The ostium of the false aneurysm measured 2 X 2 cm and was located beneath the aortic valve noncoronary cusp in the fibrous continuity between the mitral and aortic valves. The false aneurysm extended onto the superior aspect of the left atrium, ending in a blind pouch. The mitral valve was normal. The opening of the false aneurysm was closed and the aortic valve replaced with a bioprosthesis. Postoperative echocardiography showed the region of the aneurysm to be indistinct, probably because of thrombus formation. Contrast echocardiography performed through the left atria1
line showed no filling of the false aneurysm by the contrast material, confirming the security of the surgical closure.
From the Section of Cardiology, Department
of Medicine, and the of Cardiac Surgery, Department of Surgery, University of Southern California School of Medicine, Los Angeles, California. __ Manuscript received February 4, 1983; revised manuscript received and accepted March 7, 1983. Section
Aneurysms of the mitral-aortic intervalvular fibrosa are due to the spread of infection from the aortic valve. The intervalvular fibrosa attaches to the aortic root and to the anterior leaflet of the mitral valve. Perforation from infection in this area may cause an aneurysm to develop in the epicardial tissue between the aorta and
FlGUFlE 2. Contrast Zdimensional echocardiographic study (parasternal long-axis views) performed during cardiac catheterization with the catheter (C) positioned in the aortic root (upper panel). The left ventricle (LV) filled with contrast during the first diastolic interval after injection. The aneurysm (An) then filled with the first systole after injection (lower panel). No contrast material is seen in the left atrium (LA). IVS = interventricular septum; MV = mitral valve.
1802
BRIEF REPORTS
left atrium which is in direct communication with the pericardial space. Angiographic studies have been the standard method for detecting these aneurysms. However, precise definition of structures by angiography is difficult because the left ventricular outflow tract may be obscured by overlapping contrast-filled structures. In addition, the number of views is limited by the amount of contrast material that can be used in an individual patient. In our patient, contrast 2-D echocardiography was useful (1) to define that the aneurysm originated from the left side of the heart, (2) to demonstrate that the aneurysm filled from the left ventricle, and (3) to confirm obliteration of the aneurysm postoperatively. Two-dimensional echocardiography was particularly helpful because of the added spatial orientation. An echo-free space lying
between the posterior aortic root and the left atrium expanded during systole. Contrast 2-D echocardiography was then used to define its relation to the intracardiac chambers. Our case, the first to describe an aneurysm of the mitral-aortic intervalvular fibrosa by 2-D echocardiography, demonstrates the usefulness of contrast 2-D echocardiography during cardiac catheterization in defining this “complex” cardiac lesion. Acknowledgment: We acknowledge with gratitude the technical assistance of Michael Butler. References 1. Chesler E, KornsME, Porter GE, Reyes CN, Edwards JE. False aneurysm of the left ventricle secondaryto bacterial endocarditiswith perforationof the mitral-aorticintervalvularfibrosa.Circulation1966;37:516-523. 2. Gonzalez-LavinL, Scappatlna E, Llse M, RossDN. Mycoticaneurysmsof the aortic root:a complicationof aorticvalveendocarditis.Ann ThoracSurg 1970;9:551-561.
Platypnea and lnteratrial Right-to-Left Shunting After Lobectomy Robert M. Springer, MD Mihai Gheorghiade, MD C. Simon Chakko, MD George M. Bell, MD Richard 0. Cannon, III, MD Joann Urquhart, MD Michael Jones, MD Robert 0. Bonow, MD
is dyspnea in the upright position relieved in the supine position. This unusual symptom has been reported after pneumonectomy due to a new onset of right-to-left shunting through a previously unrecognized atria1 septal defect or a patent foramen ovale in the absence of pulmonary hypertension.1-5 Platypnea
A 63-year-old man presented with cough and hoarseness. X-ray disclosed a mass in the lower lobe of the right lung, and aspiration biopsy disclosed adenocarcinoma. Right lower lobectomy was performed. He was readmitted to the hospital 4 months later for dyspnea. Electrocardiography revealed sinus tachycardia and nonspecific ST-T changes. At pulmonary angiography which was negative for emboli, the 7F pigtail catheter slipped repeatedly into the left atrium. It was apparent that the patient was dyspneic and cyanotic only when erect and was comfortable in the supine position. Arterial blood gases on 40% oxygen were: pH 7.42, partial pressure of carbon dioxide 29 mm Hg, partial pressure of oxygen 81 mm Hg in the supine position, and 7.44,25 mm Hg, and 44 mm Hg, respectively, in the upright position. On 100% oxygen, partial pressure of oxygen was 56 mm Hg. The
From the Section of Cardiology, Veterans Administration Medical Center, Salem, Virginia; University of Virginia, Charlottesville, Virginia; and Cardiology and Surgery Branches, National Heart, Lung, and Blood InStitUte, National institutes of Health, Bethesda, Maryland. Manuscript received February 16, 1983; revised manuscript received March 1, 1983, accepted March 4. 1983.
FIGURE 1. Contrast 2-dimensional echocardiogram, subcostal 4chamber view. The circles indicate contrast material appearing in all 4 chambers after injection into the superior vena cava. LA = left atrium; LV = left ventricle; RA = right atrium; RV = right ventricle.
TABLE I
Hemodynamics
Pressures (mm Hg) Right atrium (mean) Right ventricle Pulmonary artery Pulmonary artery wedge Oxygen saturations (%) Mixed venous Pulmonary artery Pulmonary vein Radial artery QsfQp
Supine
Sitting
4 2013 20110 10
2 1712 17/7 7
t: t: 2.1
diagnosis of right-to-left shunt was made conclusively by contrast echocardiography. Boluses of 10 ml of saline solution were injected into the right atrium. Contrast echoes appeared in all 4 cardiac chambers only when the patient was in the sitting position (Fig. 1). Right-sided cardiac catheterization was performed (Table I). Oxygen saturation measurements (Table I) revealed a significant right-to-left atria1 level shunt only in the upright position. The systemic-to-pulmonary flow ratio (QsIQp) was 2.1. Because the patient was confined to bed, being dyspneic and cyanotic only in the upright position, percutaneous closure of the defect was attempted using an umbrella prosthesis. The umbrella failed to fix to the atria1 septum and migrated into