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Aneurysm of the membranous septum detected during left ventriculography and demonstrated by cardiac magnetic resonance imaging
International Journal of Cardiology 136 (2009) e60 – e62 www.elsevier.com/locate/ijcard
Letter to the Editor
Aneurysm of the membranous septum detected during left ventriculography and demonstrated by cardiac magnetic resonance imaging Alp Burak Catakoglu a , Vedat Aytekin b,⁎, Saide Aytekin a , Cihan Duran a , Bulent Polat a , Cemsid Demiroglu b b
a Florence Nightingale Hospital, Department of Cardiology, Turkey Istanbul Bilim University, Florence Nightingale Hospital, Department of Cardiology, Turkey
Received 31 January 2008; accepted 3 May 2008 Available online 31 July 2008
Keywords: Aneurysm of the ventricular membranous septum; Venticulography; Magnetic resonance imaging
1. Introduction Some of the membranous ventricular septal defects (VSD) in infancy transform into aneurysms of the ventricular membranous septums (AMS) later in adulthood [1,2]. It could be isolated or usually found together with VSD, atrial septal defects, aortic or pulmonary valvular malformations. AMS is generally detected incidentally during non-invasive imaging and sometimes during cardiac catheterization. We present a 52-year-old male patient with AMS observed during left ventriculography and demonstrated by magnetic resonance imaging (MRI). 2. Case A 52-year-old male patient was referred to our hospital for coronary angiography because of exertional chest pain for 2 months with an echocardiographic evidence of moderate aortic regurgitation. He did not have a previous history of systemic emboli. He is diagnosed with hypertension for 5 years and hypercholesterolemia for 4 years. He is a current smoker, with no premature coronary artery disease history in his family. Blood examination, electrocardiogram
⁎ Corresponding author. Abide-i Hurriyet C. No: 290, 34381 Sisli, Istanbul, Turkey. Tel.: +90 212 224 4950x4099; fax: +90 212 296 5222. E-mail address: [email protected] (V. Aytekin). 0167-5273/$ - see front matter © 2008 Elsevier Ltd. All rights reserved. doi:10.1016/j.ijcard.2008.05.012
and chest X-ray were non-specific. Coronary angiography was performed by using traditional Judkings technique. A 30% stenotic lesion was observed in the middle-third segment of left anterior descending artery and a 30% stenosis in the middle-third segment of the circumflex artery. The right coronary artery was normal. A calcified aneurysm was observed in the ventricular septum during left ventriculography without any contrast shunt between the ventricles (Fig. 1). Aortography revealed moderate/ severe aortic regurgitation. We performed a transthoracic echocardiogram to visualize the aneurysm and to rule out VSD. Left ventricular end-diastolic diameter was 5.6 cm, end-systolic diameter was 4.8 cm, wall thickness and motions were normal. The septum was sigmoid in shape. Ejection fraction was 58%. Left atrium was dilated (4.2 cm) and mild mitral regurgitation was observed. Aortic root (3.6 cm) and the ascending aorta was dilated (4 cm). Moderate aortic regurgitation was detected. No gradient was measured both in the left and right ventricular outflow tracts. VSD was not observed by echocardiography and the aneurysm could not be optimally visualized. Cardiac MRI was performed using Siemens Magnetom Sonata system. Multiplane True FISP cine sequences showed an AMS inferior to the aortic valve, protruding into the right ventricle (Fig. 2). The shape of the aneurysm was stable both during systole and diastole, without any shunt flow between the ventricles. Thrombus was absent in the aneurysm. Aortic valve replacement was performed and
A.B. Catakoglu et al. / International Journal of Cardiology 136 (2009) e60–e62
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Fig. 1. Left ventriculography in the left anterior oblique projection showing the aneurysm of the membranous septum (arrow) (A). Aortography in the right oblique projection showing the aneurysm (arrow) inferior to the aortic valve, which fills with contrast that regurgitates from the aortic valve due to moderate aortic regurgitation (B).
the aneurysm was plicated during the surgery. He still is event-free for 8 months. 3. Discussion AMS is a congenital anomaly that is formed by the transformation of VSD during adulthood [1,2]. It is considered as a type among the left ventricular outflow tract aneurysms [3]. Although most cases are silent, AMS may be associated with systemic emboli, endocarditis, cardiac arrhythmias, left or right ventricular outflow tract obstruction and right-to-left shunts secondary to ruptures [4–7]. The thin membrane of the aneurysm typically arises from the margin of the VSD and usually incorporates with the septal leaflet of the tricuspid valve [8]. As in our case, it often protrudes into the right ventricle, whereas sometimes right atrial protrusion could also be observed [3]. Echocardiography is an effective modality for the diagnosis of AMS, however it has limitations for detailed morphological assessment. According to Canale et al. the sensitivity to detect AMS was 87.5% in the long-axis view, 71% in the apical four-chamber view, 62% in
the short-axis view, and 57% in the subcostal four-chamber view [9]. Multislice computed tomography is another alternative diagnostic tool to detect AMS, which has advantages in morphological assessment with three-dimensional view [10]. We preferred to use cardiac-MRI in our case because we aimed to perform both anatomical and functional assessment of the AMS, observed during left ventriculography, without any extra exposure of radiation and contrast media. Cardiac MRI is capable of three-dimensional anatomical assessment and provides functional data about the blood flow into the aneurysm and integrity of the ventricular membranous septum. Left ventriculogram might detect AMS, whereas it is not able to inform on the presence of thrombus, and is an invasive procedure. Surgery is usually considered in AMS cases complicated with either thrombus and related systemic emboli, rupture, or accompanying significant VSD. We surgically treated the aneurysm in this case because aortic valve had an indication for prosthetic replacement; therefore a simple plication was easy to perform with a potential advantage for any future surgical need. In conclusion, AMS could be detected during left
Fig. 2. True FISP cine sequence of the left ventricle by cardiac magnetic resonance imaging showing aneurysm of the membranous ventricular septum (arrow) in the oblique coronal (A) and oblique axial plane (B).
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ventriculography, and cardiac MRI might be considered as a useful diagnostic tool both for morphological and functional assessment. References [1] Ramaciotti C, Keren A, Silverman NH. Importance of (perimembranous) ventricular septal aneurysm in the natural history of isolated perimembranous ventricular septal defect. Am J Cardiol Feb 1 1986;57(4):268–72. [2] Miyake T, Shinohara T, Nakamura Y, et al. Aneurysm of the ventricular membranous septum: serial echocardiographic studies. Pediatr Cardiol Jul–Aug 2004;25(4):385–9. [3] Meier JH, Seward JB, Miller Jr FA, et al. Aneurysms in the left ventricular outflow tract: clinical presentation, causes, and echocardiographic features. J Am Soc Echocardiogr Jul 1998;11(7):729–45. [4] Graffigna A, Minzioni G, Ressia L, et al. Surgical ablation of ventricular tachycardia secondary to congenital ventricular septal aneurysm. Ann Thorac Surg Apr 1994;57(4):921–4.
[5] Ignaszewski AP, Collins-Nakai RL, Kasza LA, et al. Aneurysm of the membranous ventricular septum producing subpulmonic outflow tract obstruction. Can J Cardiol Jan–Feb 1994;10(1):67–70. [6] Sharma A, Kern MJ, Callicoat P, et al. Severe subpulmonic outflow obstruction caused by aneurysm of the membranous ventricular septum: diagnosis by transesophageal echocardiography. Am Heart J Mar 1992;123(3):810–4. [7] Walpot J, Peerenboom P, van Wylick A, et al. Aneurysm of the membranous septum with ventricular septal defect and infective endocarditis. Eur J Echocardiogr Oct 2004;5(5):391–3. [8] Feigenbaum H, Armstrong WF, Ryan T. Feigenbaum's echocardiography. 6th ed. Philadelphia: Lippincott Williams & Wilkins; 2005. [9] Canale JM, Sahn DJ, Valdes-Cruz LM, et al. Accuracy of twodimensional echocardiography in the detection of aneurysms of the ventricular septum. Am Heart J Mar 1981;101(3):255–9. [10] Komatsu S, Sato Y, Omori Y, et al. Aneurysm of the membranous interventricular septum demonstrated by multislice computed tomography. Int J Cardiol Jan 2 2007;114(1):123–4.
Letter to the Editor
Aneurysm of the membranous septum detected during left ventriculography and demonstrated by cardiac magnetic resonance imaging Alp Burak Catakoglu a , Vedat Aytekin b,⁎, Saide Aytekin a , Cihan Duran a , Bulent Polat a , Cemsid Demiroglu b b
a Florence Nightingale Hospital, Department of Cardiology, Turkey Istanbul Bilim University, Florence Nightingale Hospital, Department of Cardiology, Turkey
Received 31 January 2008; accepted 3 May 2008 Available online 31 July 2008
Keywords: Aneurysm of the ventricular membranous septum; Venticulography; Magnetic resonance imaging
1. Introduction Some of the membranous ventricular septal defects (VSD) in infancy transform into aneurysms of the ventricular membranous septums (AMS) later in adulthood [1,2]. It could be isolated or usually found together with VSD, atrial septal defects, aortic or pulmonary valvular malformations. AMS is generally detected incidentally during non-invasive imaging and sometimes during cardiac catheterization. We present a 52-year-old male patient with AMS observed during left ventriculography and demonstrated by magnetic resonance imaging (MRI). 2. Case A 52-year-old male patient was referred to our hospital for coronary angiography because of exertional chest pain for 2 months with an echocardiographic evidence of moderate aortic regurgitation. He did not have a previous history of systemic emboli. He is diagnosed with hypertension for 5 years and hypercholesterolemia for 4 years. He is a current smoker, with no premature coronary artery disease history in his family. Blood examination, electrocardiogram
⁎ Corresponding author. Abide-i Hurriyet C. No: 290, 34381 Sisli, Istanbul, Turkey. Tel.: +90 212 224 4950x4099; fax: +90 212 296 5222. E-mail address: [email protected] (V. Aytekin). 0167-5273/$ - see front matter © 2008 Elsevier Ltd. All rights reserved. doi:10.1016/j.ijcard.2008.05.012
and chest X-ray were non-specific. Coronary angiography was performed by using traditional Judkings technique. A 30% stenotic lesion was observed in the middle-third segment of left anterior descending artery and a 30% stenosis in the middle-third segment of the circumflex artery. The right coronary artery was normal. A calcified aneurysm was observed in the ventricular septum during left ventriculography without any contrast shunt between the ventricles (Fig. 1). Aortography revealed moderate/ severe aortic regurgitation. We performed a transthoracic echocardiogram to visualize the aneurysm and to rule out VSD. Left ventricular end-diastolic diameter was 5.6 cm, end-systolic diameter was 4.8 cm, wall thickness and motions were normal. The septum was sigmoid in shape. Ejection fraction was 58%. Left atrium was dilated (4.2 cm) and mild mitral regurgitation was observed. Aortic root (3.6 cm) and the ascending aorta was dilated (4 cm). Moderate aortic regurgitation was detected. No gradient was measured both in the left and right ventricular outflow tracts. VSD was not observed by echocardiography and the aneurysm could not be optimally visualized. Cardiac MRI was performed using Siemens Magnetom Sonata system. Multiplane True FISP cine sequences showed an AMS inferior to the aortic valve, protruding into the right ventricle (Fig. 2). The shape of the aneurysm was stable both during systole and diastole, without any shunt flow between the ventricles. Thrombus was absent in the aneurysm. Aortic valve replacement was performed and
A.B. Catakoglu et al. / International Journal of Cardiology 136 (2009) e60–e62
e61
Fig. 1. Left ventriculography in the left anterior oblique projection showing the aneurysm of the membranous septum (arrow) (A). Aortography in the right oblique projection showing the aneurysm (arrow) inferior to the aortic valve, which fills with contrast that regurgitates from the aortic valve due to moderate aortic regurgitation (B).
the aneurysm was plicated during the surgery. He still is event-free for 8 months. 3. Discussion AMS is a congenital anomaly that is formed by the transformation of VSD during adulthood [1,2]. It is considered as a type among the left ventricular outflow tract aneurysms [3]. Although most cases are silent, AMS may be associated with systemic emboli, endocarditis, cardiac arrhythmias, left or right ventricular outflow tract obstruction and right-to-left shunts secondary to ruptures [4–7]. The thin membrane of the aneurysm typically arises from the margin of the VSD and usually incorporates with the septal leaflet of the tricuspid valve [8]. As in our case, it often protrudes into the right ventricle, whereas sometimes right atrial protrusion could also be observed [3]. Echocardiography is an effective modality for the diagnosis of AMS, however it has limitations for detailed morphological assessment. According to Canale et al. the sensitivity to detect AMS was 87.5% in the long-axis view, 71% in the apical four-chamber view, 62% in
the short-axis view, and 57% in the subcostal four-chamber view [9]. Multislice computed tomography is another alternative diagnostic tool to detect AMS, which has advantages in morphological assessment with three-dimensional view [10]. We preferred to use cardiac-MRI in our case because we aimed to perform both anatomical and functional assessment of the AMS, observed during left ventriculography, without any extra exposure of radiation and contrast media. Cardiac MRI is capable of three-dimensional anatomical assessment and provides functional data about the blood flow into the aneurysm and integrity of the ventricular membranous septum. Left ventriculogram might detect AMS, whereas it is not able to inform on the presence of thrombus, and is an invasive procedure. Surgery is usually considered in AMS cases complicated with either thrombus and related systemic emboli, rupture, or accompanying significant VSD. We surgically treated the aneurysm in this case because aortic valve had an indication for prosthetic replacement; therefore a simple plication was easy to perform with a potential advantage for any future surgical need. In conclusion, AMS could be detected during left
Fig. 2. True FISP cine sequence of the left ventricle by cardiac magnetic resonance imaging showing aneurysm of the membranous ventricular septum (arrow) in the oblique coronal (A) and oblique axial plane (B).
e62
A.B. Catakoglu et al. / International Journal of Cardiology 136 (2009) e60–e62
ventriculography, and cardiac MRI might be considered as a useful diagnostic tool both for morphological and functional assessment. References [1] Ramaciotti C, Keren A, Silverman NH. Importance of (perimembranous) ventricular septal aneurysm in the natural history of isolated perimembranous ventricular septal defect. Am J Cardiol Feb 1 1986;57(4):268–72. [2] Miyake T, Shinohara T, Nakamura Y, et al. Aneurysm of the ventricular membranous septum: serial echocardiographic studies. Pediatr Cardiol Jul–Aug 2004;25(4):385–9. [3] Meier JH, Seward JB, Miller Jr FA, et al. Aneurysms in the left ventricular outflow tract: clinical presentation, causes, and echocardiographic features. J Am Soc Echocardiogr Jul 1998;11(7):729–45. [4] Graffigna A, Minzioni G, Ressia L, et al. Surgical ablation of ventricular tachycardia secondary to congenital ventricular septal aneurysm. Ann Thorac Surg Apr 1994;57(4):921–4.
[5] Ignaszewski AP, Collins-Nakai RL, Kasza LA, et al. Aneurysm of the membranous ventricular septum producing subpulmonic outflow tract obstruction. Can J Cardiol Jan–Feb 1994;10(1):67–70. [6] Sharma A, Kern MJ, Callicoat P, et al. Severe subpulmonic outflow obstruction caused by aneurysm of the membranous ventricular septum: diagnosis by transesophageal echocardiography. Am Heart J Mar 1992;123(3):810–4. [7] Walpot J, Peerenboom P, van Wylick A, et al. Aneurysm of the membranous septum with ventricular septal defect and infective endocarditis. Eur J Echocardiogr Oct 2004;5(5):391–3. [8] Feigenbaum H, Armstrong WF, Ryan T. Feigenbaum's echocardiography. 6th ed. Philadelphia: Lippincott Williams & Wilkins; 2005. [9] Canale JM, Sahn DJ, Valdes-Cruz LM, et al. Accuracy of twodimensional echocardiography in the detection of aneurysms of the ventricular septum. Am Heart J Mar 1981;101(3):255–9. [10] Komatsu S, Sato Y, Omori Y, et al. Aneurysm of the membranous interventricular septum demonstrated by multislice computed tomography. Int J Cardiol Jan 2 2007;114(1):123–4.