Repair of recurrent pseudoaneurysm of the mitral-aortic intervalvular fibrosa: Role of transesophageal echocardiography
Shreedhar S Joshi1, Ashwini Thimmarayappa1, PS Nagaraja1, AM Jagadeesh1, Arul Furtado2, Seetharam Bhat2 1 Department of Cardiac Anesthesia, Sri Jayadeva Institute of Cardiovascular Sciences and Research, Bengaluru, Karnataka, India 2 Department of Cardiac Surgery, Sri Jayadeva Institute of Cardiovascular Sciences and Research, Bengaluru, Karnataka, India
Pseudoaneurysm of mitral-aortic intervalvular fibrosa (P-MAIVF) is a rare cardiac surgical condition. P-MAIVF commonly occurs as a complication of aortic and mitral valve replacement surgeries. The surgical trauma during replacement of the valves weakens the avascular mitral and aortic intervalvular area. We present a case of P-MAIVF recurrence 5 years after a primary repair. Congestive cardiac failure was the presenting feature with mitral and aortic regurgitation. In view of the recurrence, the surgical team planned for a double valve replacement. The sewing rings of the two prosthetic-valves were interposed to close the mouth of the pseudoaneurysm and to provide mechanical reinforcement of the MAIVF. Intra-operative transesophageal echocardiography (TEE) helped in delineating the anatomy, extent of the lesion, rupture of one of the pseudoaneurysm into left atrium and severity of the valvular regurgitation. Post-procedure TEE confirmed complete obliteration of the pseudoaneurysm and prosthetic valve function.
How to cite this article: Joshi SS, Thimmarayappa A, Nagaraja P S, Jagadeesh A M, Furtado A, Bhat S. Repair of recurrent pseudoaneurysm of the mitral-aortic intervalvular fibrosa: Role of transesophageal echocardiography. Ann Card Anaesth 2014;17:152-4
How to cite this URL: Joshi SS, Thimmarayappa A, Nagaraja P S, Jagadeesh A M, Furtado A, Bhat S. Repair of recurrent pseudoaneurysm of the mitral-aortic intervalvular fibrosa: Role of transesophageal echocardiography. Ann Card Anaesth [serial online] 2014 [cited 2021 Oct 22];17:152-4. Available from: https://www.annals.in/text.asp?2014/17/2/152/129870
Introduction
Pseudoaneurysm of the mitral-aortic intervalvular fibrosa (P-MAIVF) is a rare clinical entity. P-MAIVF commonly occurs as a complication of aortic and mitral valve replacement surgeries. [1] Perhaps, the surgical trauma during replacement of the valves weakens the avascular mitral and aortic intervalvular fibrosa and the stress to MAIVF caused by the left ventricular stroke volume over a long period possibly results in the formation of a pseudoaneurysm. Pseudoaneurysms may also be precipitated by infective endocarditis (IE) and formation of abscess. [1],[2] P-MAIVF might also be present without any precipitating cardiac lesions. Surgical management is the cornerstone of treatment for P-MAIVF; however, catheter based interventional procedures have been utilized to manage small uncomplicated lesions. [3],[4],[5] Recurrence after surgical repair is rare and difficult to manage. [6] We describe recurrence of P-MAIVF 5 years after surgical repair. The patient presented with features of congestive cardiac failure, mitral regurgitation (MR), aortic regurgitation (AR) and rupture of one of the pseudoaneurysm into left atrium (LA). Transesophageal echocardiography (TEE) confirmed the presence of the pseudoaneurysm, delineated the anatomical extent of the lesions and helped in the assessment of the accuracy of surgical procedure.
Case Report
A 32-year-old male patient presented with congestive heart failure. Clinical examination revealed cardiomegaly, grade II/III diastolic murmur, grade III/IV long systolic murmur and pulmonary congestion. Past medical history revealed surgical repair of P-MAIVF 5 years ago. TTE demonstrated recurrence of the pseudoaneurysm, mild to moderate MR, severe AR, and enlarged left ventricle (LV). A clinical diagnosis of recurrence of P-MAIVF with AR and MR was put forth. Informed consent to replace the mitral and aortic valves and for the repair of P-MAIVF and for the information to be shared for academic purpose, was obtained from the patient.
After induction of anesthesia and placement of invasive lines, TEE probe (Philips EnVisor) was introduced. Images were acquired and stored for analysis. Four chamber and modified four chamber views showed multiple sacs within the interatrial septum (IAS) during systole and diastole [Video 1] , [Figure 1]a. One of the sacs was continuous with the left atrium (LA) indicating rupture into it [Figure 1]b. The bicaval view also demonstrated the sac opening into LA [Video 2] , [Figure 2]d. MR was moderate to severe with eccentric jet on TTE and TEE images [Video 3] . The MR jet was associated with a jet from the pseudoaneurysm to LA during systole. Mid-esophageal LV long axis (ME LV LAX) view showed anteriorly displaced aortic valve due to large P-MAIVF. This simulated a double aorta [Figure 1]c, [Figure 2]a and b, filling in systole and emptying in diastole [Video 4] , [Figure 2]a and b. Pulsatility was also demonstrated by pulse wave (PW) interrogation of the pseudoaneurysm [Figure 2]c. AR was difficult to assess due to the diastolic flows from both aorta and pseudoaneurysm. Holodiastolic flow reversal in aortic arch confirmed the diagnosis of severe AR.
Figure 1: Transesophageal (TEE) and transthoracic (TTE) pre-cardiopulmonary bypass images. (a) Mid-esophageal four chamber view shows mitral regurgitation jet and jet from pseudoaneurysm (PsA) in left atrium (LA). (b) One of the PsA open into LA. (c) TEE imaging shows a PsA between mitral and aortic openings, which looks like a double aorta. (d) TTE shows similar image
Figure 2: Transthoracic pre-operative images showing difficulty in assessment of aortic regurgitation due to the diastolic jet from pseudoaneurysm (PsA) (a: Systole, b: Diastole). (c) Transesophageal (TEE) - pulse wave interrogation depicts pulsatility in PsA. (d) TEE - Bicaval view (108°) demonstrating PsA opening into left atrium
The standard hypothermic cardiopulmonary bypass (CPB) was established and the mitral and aortic valves were replaced with 29 mm and 27 mm Chitra-TTK prosthetic valves, respectively (TTK Health Care Limited, India). The myocardium was protected by hyperkalemic blood cardioplegia. The CPB and aortic cross-clamp times were 274 and 197 min, respectively. The mouth of P-MAIVF was obliterated by interposing it between the two prosthetic valve-sewing rings. Dopamine 5 μg/kg/min was started to facilitate weaning from CPB. Post-operative TEE confirmed complete obliteration of P-MAIVF [Video 5] , [Figure 3]a and ruled out malfunction of prostheses or any new regional wall motion abnormalities. Post-operative period remained uneventful and the patient was weaned from ventilator 24 h later. TTE performed on first post-operative day for assessment of prostheses and obliteration of P-MAIVF [Figure 3]b showed complete obliteration of P-MAIVF and normal function of both the valve prostheses.
Figure 3: Post-Double Valve Replacement (DVR) images. (a) Transesophageal mid-esophageal four chamber view (0°) confirms obliteration of pseudoaneurysm (PsA). (b) Post-operative day 2 - TTE images confirm obliteration of PsA
The P-MAIVF is a rare clinical condition occurring commonly after aortic valve surgeries and rarely after chest trauma. Most reports in the literature are of cases associated with aortic valve surgeries, infective endocarditis and aortic root abscess. [1] MAIVF is situated postero-lateral to aortic valve and LV outflow tract due to which it is continuously exposed to the high velocity jet of blood ejected from LV, which might weaken the MAIVF making it vulnerable to recurrence of the pseudoaneurysm. Moreover, this area is relatively avascular. Earlier, the authors published a case of P-MAIVF without any associated cardiac lesions, [7] the patient was managed with obliteration of the pseudoaneurysm and strengthening of the MAIVF region with Dacron patch. The authors emphasized the importance of intra-operative TEE assessment in managing such cases. The present case is a recurrence of P-MAIVF after successful repair. A case-involving trauma to MAIVF region during aortic valve replacement has also been reported. The trauma to MAIVF was detected by TEE and the repair involved a U-suture taken from outside the aorta to obliterate pseudoaneurysm and to strengthen the region. [8] Similar reports of P-MAIVF after a few weeks of aortic valve replacement have been published. In these reports, repair was performed with redo-AVR and patch closure of P-MAIVF. [9],[10] The present patient also had undergone repair of P-MAIVF which failed and recurred. Recurrence with MR and AR favored Double Valve Replacement (DVR) wherein the MAIVF region was interposed between the two prosthetic valve-sewing rings. This provided a mechanical reinforcement of the region expecting prevention of further recurrence.
David etal., in their study have suggested use of tailor made Dacron patch or pericardium to reconstruct the MAIVF region. Significant freedom from reoperation has been achieved with this technique. [11],[12] A similar technique was employed in the present case during primary surgical repair. Two case series of DVR with lesions of MAIVF are reported. [12] The operative indications for the repair of MAIVF in these cases were IE with severe valvular regurgitation, small and fragile annuli, active IE with abscess, extensive calcification of the mitral annulus and interventricular fibrous body and lack of fibrous tissue to secure a prosthetic valve. The indication for repair of MAIVF in the present case was the pseudoaneurysm in MAIVF, which is distinct from the usual indications.
To summarize, we present a case of recurrence of P-MAIVF lesion with significant MR and AR. The P-MAIVF opening was interposed between the prosthetic valve sewing rings. Complete obliteration of P-MAIVF was confirmed with TEE after surgical repair.
Acknowledgment
We acknowledge Dr. Aparna Srinivasa Babu for editing the manuscript.
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Correspondence Address: Shreedhar S Joshi Department of Cardiac Anesthesia, Sri Jayadeva Institute of Cardiovascular Sciences and Research, Bengaluru - 560 069, Karnataka India
Source of Support: Institutional Support, Conflict of Interest: None
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