Cross-sectional echocardiographic recognition of submitral left ventricular aneurysm

Internutionul

Journul

of Cardiology.

14 (1987)

327

327-332

Elsevier

IJC 00503

Cross-sectional echocardiographic recognition of submitral left ventricular aneurysm Satyavan Depurttnent

Sharma,

of Curdiologv

Ajit G. Desai,

und Curdiuc

Surgq:

BYL

(Muhurushtru),

(Received

Nuir

S.S. Bhattacharya Houpttul

und KEM

* Hospitul.

Bomhu~

In&

22 April 19X6; revision accepted

1 October

1986)

Sharma S, Desai AG, Bhattacharya SS. Cross-sectional echocardiographic tion of submitral left ventricular aneurysm. Int J Cardiol 1987;14:327-332.

recogni-

Three cases of annular submitral left ventricular aneurysm precisely diagnosed by cross-sectional echocardiography are reported from the Indian subcontinent. The cineangiographic findings are available in all and morphologic findings in two cases. The apical four-chamber view demonstrated a characteristically large aneurysm arising below the mural leaflet of the mitral valve extending anterolaterally and posteriorly and communicating with the left ventricular cavity in all the cases. Contrast echocardiography performed during cardiac catheterisation promises to be a good technique for the qualitative assessment of the associated mitral regurgitation. Cross-sectional echocardiography is invaluable in diagnosis and assessment of results of surgery in this entity. (Key words: Annular trast echocardiography)

submitral

aneurysm;

Cross-sectional

echocardiography;

Con-

Introduction Annular subvalvar nonischemic aneurysms of the left ventricle initially described from Nigeria in a Negro patient [l] are so unusual in this country that they rank as medical curiosities. The clinical, radiologic, cineangiographic and pathologic features have been well documented in excellent reports from South Africa [2], Uganda [3] and Brazil [4]. There is only one case report, however, describing echocardio-

Correspondence to: Dr. Satyavan Sharma, Department of Cardiology, BYL Nair Hospital. 400 008 (Maharashtra), India. * Present uddress: Jaslok Hospital and Research Centre. Bombay (Maharashtra). India.

O167-5273/87/$03.50

6~ 1987 Elsevier

Science Publishers

B.V. (Biomedical

Division)

Bombay

328

graphic findings in this entity [5]. The rarity of reports from countries where these aneurysms are seen prompted us to report our experience with cross-sectional echocardiography in noninvasive recognition of this entity in three cases.

Patients and Methods We have studied three cases of annular submitral aneurysm of the left ventricle during the last three years. An analysis of clinical records, echocardiograms and other data was made in these patients. Cross-sectional echocardiography was performed in all the cases using Diasonics cardiovue-3400 @ phased array sector scanner. The recordings were made in multiple planes using apical, parasternal and subcostal windows. Contrast echocardiography was performed in one case during cardiac catheterisation by injection of 3-5 ml of 5% glucose through a pigtail catheter placed in the left ventricular aneurysm. Cineangiographic confirmation of the diagnosis was available in all the cases. Two patients underwent surgery and the detailed morphologic findings are available in both.

Results There were two men and one woman, ages 12-29 years (average patients came from the Maharashtra State of India and included one Muslim patient.

21 years). All the two Hindus and

Clinical Features The duration of symptoms varied between 8 weeks and 6 months. The clinical presentation in all cases was dominated by congestive cardiac failure. Cases 1 and 3 had gross cardiomegaly, markedly prominent apical, parasternal and epigastric pulsations, S3 gallop and the pansystolic murmur of mitral regurgitation. The findings in case 2, although similar, were less remarkable. The antero-posterior chest radiograph showed varying degree of cardiomegaly, bulging of the left cardiac border, a prominent left atrium and signs of pulmonary venous hypertension in all the cases. Calcification within the hump along the left cardiac border was observed in case 1. The electrocardiogram in all cases revealed sinus rhythm, Q waves in I, avl and generalised ST-T changes. Patient 1 died following surgery, the second patient underwent successful excision of the aneurysm and is doing well at the end of 30-month follow-up while the third patient refused surgery. Diagnostic Observations Case 1. Cross-sectional echocardiographic recordings in parasternal long axis (Fig. 1, left panel) and apical four-chamber views (Fig. 1, right panel) revealed a large subvalvar aneurysm arising below the mural leaflet of the mitral valve and

329

Fig. 1. Cross-sectional echocardiograms in parasternal long axis (left panel) and apical four-chamber (right panel) views in case 1 revealing a large submitral aneurysm extending anterolaterally and posteriorly. RV = right ventricle; RA = right atrium; TV = tricuspid valve: A0 = aorta; LV = left ventricle: LA = left atrium: MV = mitral valve.

extending anterolaterally and posteriorly. The massive aneurysm shifted the right atrium, right ventricle, interatrial septum and interventricular septum to the right and resulted in distortion in the shape of these structures. No clot was detected in the left ventricle or the aneurysm. The aneurysm communicated with the left ventricular cavity below the region of mitral annulus. The left main coronary artery appeared normal. Proper visualisation of the coronary arteries was not possible by cross-sectional echocardiography. Hemodynamic studies, summarised in Table 1, revealed marked elevation of the left ventricular end-diastolic pressure and moderate pulmonary arterial hypertension. Cineangiography demonstrated normal coronary arteries and established the diagnosis of annular submitral aneurysm of the left ventricle with areas of calcification within the aneurysm and grade 2/4 mitral regurgitation. The patient died following open heart surgery. Autopsy revealed a markedly enlarged heart with

TABLE

1

Hemodynamic

observations

Site

Pressure

(mm Hg)

Case 1 PW

23

PT R\

60/22 60/10

RA LV

100/25

Aorta

loo/70

Case 2

Case 3

is w

30/15 30/u

10

18 i% ii

100/1x 90

50/1x 50/6

loo/70

PW = pulmonary wedge; PT = pulmonary trunk; atrium: lines above numbers = mean pressure.

74 6

110/20 w RV = right ventricle:

110/70 LV = left ventricle:

100 RA = right

PRE

OP

POST

OP

Fig. 2. Cross-sectional echocardiograms in case 2 in apical four-chamber view. The pre-operative study (left panel) reveals the submitral aneurysm. The right panel reveals the normal contour of the left ventricle following operation (OP). Abbreviations as in Fig. 1.

massive dilation of the left ventricle and left atrium. The coronary arteries were normal. An annular submitral aneurysm was observed burrowing to the external surface of the heart. It formed a large blind pouch which was separated from the left atria1 cavity by a fibrous wall. The wall of the aneurysm was composed of white, sclerosed and calcified material. Case 2. Cross-sectional echocardiographic (Fig. 2, left panel), hemodynamic (Table 1) and cineangiographic findings in this case were similar to those described in case 1. Under cardiopulmonary bypass the aneurysm was resected and myocardial defect was closed with silk mattress sutures. The patient had an uneventful recovery and there was marked symptomatic improvement. Cross-sectional echocardiography performed 6 weeks after surgery in the apical four-chamber view revealed a normal contour of the left ventricle (Fig. 2, right panel). The patient continues to be asymptomatic at 30-month follow-up. Case 3. Cross-sectional echocardiographic examination in the apical four-chamber view revealed a subvalvar annular aneurysm of the left ventricle with features similar to those observed in .cases 1 and 2 (Fig. 3, left upper panel). Contrast echocardiographic studies (performed during cardiac catheterisation by an injection of 5% glucose through a pigtail catheter placed in the aneurysm) demonstrated passage of contrast to the left ventricular cavity and then to the left atrium owing to mitral regurgitation (Fig. 3, right upper panel). There was no clot detected in the left ventricular cavity or aneurysm. The hemodynamic data are summarised in Table 1. Coronary angiography revealed displacement of the left anterior descending and left circumflex artery. Left ventriculography confirmed the presence of a large subvalvar aneurysm extending posteriorly with displacement of the left atrium and grade 2/4 mitral regurgitation. Selective injection into the aneurysm demonstrated it to be

Fig. 3. Cross-sectional echocardiography in case 3 in apical four-chamber view reveals the large submitral aneurysm (left upper panel). Contrast echocardiography performed by direct injection of 5% glucose into the aneurysm through pigtail catheter reveals passage of contrast into left ventricle (LV) and demonstrates regurgitation into the left atrium (LA) (right upper panel). Selective pressure injection into the aneurysm revealed its globular shape and showed it to be poorly contracting and communicating with the left ventricle (lower panel).

globular in shape, with left ventricular

poorly contracting, without cavity (Fig. 3, lower panel).

a filling defect and communicating The patient refused surgery.

Discussion The presenting manifestations of annular submitral aneurysm include heart failure, thromboembolism, sudden death or symptoms due to compression of the left atrium or impairment of coronary blood flow [1,2]. Clinical recognition is difficult and in most reported cases, the diagnosis was made at autopsy [1,3,6]. Echocardiography is an established technique for the diagnosis of both ventricular aneurysm or pseudoaneurysm secondary to coronary artery disease [7,8], and congenital diverticuli of the left ventricle [9]. There is only one case report [5], however, regarding the use of this technique in diagnosis of annular submitral aneurysm. Our experience suggests that precise noninvasive diagnosis is possible by cross-sectional echocardiography. The heart is often displaced in these cases to the

332

right with resultant distortion of morphology of the cardiac chambers. For precise diagnosis, it is essential that recordings are made from multiple sites using apical, parasternal and subcostal windows. The apical four-chamber view proved most useful and revealed similar and characteristic findings in each case. Typically, all cases had a large aneurysm arising below the mural leaflet of the mitral valve which communicated with the left ventricle. There was resultant displacement of adjacent cardiac structures. Contrast echocardiography performed during cardiac catheterisation in case 3 proved superior to cineangiographic pressure injections in delineating the anatomic details of the aneurysm, establishing the communication with the left ventricle and for diagnosing the presence of mitral regurgitation. Contrast echocardiography can obviate the necessity of potentially dangerous multiple cineangiographic pressure injections. Operative repair of the aneurysm seems to be the most appropriate management. The risks associated with medical management alone include congestive heart failure, thromboembolic phenomena, acute coronary insufficiency and the risk of rupture. When Abrahams et al. [l] presented their series in 1962, they believed that surgery offered the only rational treatment. Cardiopulmonary bypass was not available at that time. With the recent advances made in cardiopulmonary bypass, the morbidity and mortality associated with the surgical repair of this lesion should be less. Surgery produced gratifying results in case 2 which were demonstrated by cross-sectional echocardiography. It is suggested that serial echocardiography should be used during postoperative follow up and also in patients awaiting surgery to identify progressive enlargement of the aneurysm, if any. The characteristic findings demonstrated by cross-sectional echocardiography should facilitate noninvasive recognition of annular submitral aneurysms in areas where these aneurysms are endemic. Cardiac catheterisation is necessary, however, to delineate the coronary arterial anatomy. References 1 Abrahams DG, Barton CJ, Cockshott WP. Edington GM, Weaver EJM. Annular subvalvular left ventricular aneurysms. Q J Med 1962;31:345-360. 2 Chesler E, Joffe N, Schamroth L, Meyers A. Annular subvalvular left ventricular aneurysms in the South African Bantu. Circulation 1965;32:43-51. 3 Poltera AA, Jones WA. Subvalvular left ventricular aneurysms. A report of 5 Ugandan cases. Br Heart J 1973;35:1085-1091. 4 Guimaraes AC, Filho AS, Esteves JP, et al. Annular subvalvular left ventricular aneurysms in Bahia, Brazil, Br Heart J 1976;38:1080-1085. 5 Davis MD, Caspi A, Lewis BS, Milner S, Colsen PR, Barlow JB. Two-dimensional echocardiographic features of submitral left ventricular aneurysm. Am Heart J 1982;103:289-290. 6 Korula A, Vaska K, Bakthavizhayam A, John S, Jairaj P, Murlidharan S. Idiopathic annular subvalvar left ventricular aneurysm. Indian Heart J 1983;35:184-186. 7 Weyman AE, Peskoe SM, Williams ES, Dillon JC, Feigenbaum H. Detection of left ventricular aneurysm by cross-sectional echocardiography. Circulation 1976;54:936-944. 8 Gatewood RP, Nanda NC. Differentiation of left ventricular pseudoaneurysm from the true aneurysm with two-dimensional echocardiography. Am J Cardiol 1980;46:869-878. 9 Mardini MK. Congenital diverticulum of the left ventricle - report of two unusual cases. Br Heart J 1984:51:321-326.