Pseudoaneurysm of the mitral-aortic intervalvular fibrosa in a patient with a history of bentall operation
Ali Hosseinsabet1, Kyomars Abbasi2 1 Department of Cardiology, Tehran Heart Center, Tehran University of Medical Sciences, Tehran, I.R. Iran 2 Department of Cardiac Surgery, Tehran Heart Center, Tehran University of Medical Sciences, Tehran, I.R. Iran
How to cite this article: Hosseinsabet A, Abbasi K. Pseudoaneurysm of the mitral-aortic intervalvular fibrosa in a patient with a history of bentall operation. Ann Card Anaesth 2021;24:120-1
How to cite this URL: Hosseinsabet A, Abbasi K. Pseudoaneurysm of the mitral-aortic intervalvular fibrosa in a patient with a history of bentall operation. Ann Card Anaesth [serial online] 2021 [cited 2021 Oct 16];24:120-1. Available from: https://www.annals.in/text.asp?2021/24/1/120/307758
To the Editor,
A 60-year-old man with a history of fever of 1-month duration was referred to our hospital for transthoracic echocardiography. The patient also had a history of descending aortic dissection in the context of untreated aortic coarctation 8 years previously, for which he had undergone thoracic endovascular repair, stent coarctoplasty, and right femoral-femoral artery bypass. Six months before his referral to us, he underwent the Bentall surgery because of the bicuspid aortic valve with severe stenosis and ascending aortic aneurysm. Medical evaluations due to the patient's fever and urinary tract symptoms before his admission to our hospital showed an abscess in his prostate.
In our center, physical examinations were unremarkable and laboratory data demonstrated anemia and increased erythrocyte sedimentation rate. Transthoracic echocardiography illustrated a suspicious pulsatile space between the mitral and aortic valves without any other findings in color Doppler study. Trans esophageal echocariography revealed a large pseudo aneurysm (44 × 16 mm) in the mitral-aortic inter valvular fibrosa with some mobile particles in this space that were attached to the posterior wall of the aortic tube graft. In addition, there was elevated pressure in the pseudo aneurysm during systole, resulting in the deformation of the aortic tube graft. Computed tomography angiography of the aorta confirmed the presence of contrast agents in the posterolateral space of the aortic tube graft. Blood culture was negative for microorganism growth [Figure 1], [videos 1-3]. The prostatic abscess was drained, and its culture showed Enterococcus faecalis growth. The patient underwent redo Bentall surgery and was treated with linezolid before and after surgery. He was discharged after the completion of an antibiotic course, and he had no complaints at 6 month's follow-up.
Figure 1: (a) Upper esophageal short-axis view of the aortic tube graft in transesophageal echocardiography shows an echo-free space in the posterior circumference of the aortic tube graft suggestive of a pseudoaneurysm in the mitral-aortic intervalvular fibrosa (b) accompanied by the systolic deformation of the aortic tube graft. (c) Long-axis view of the aortic valve in transesophageal echocardiography shows an echo-free space between the mitral and aortic valves (prosthesis) connected to the left ventricular outflow tract (d) with the entrance of the flow into this space in systole, suggestive of a pseudoaneurysm in the mitral-aortic intervalvular fibrosa. (e) Computed tomography angiography of the ascending aorta shows the contrast agent in the posterolateral space of the aortic tube graft in transverse and (f) frontal views. (g) Postoperative long-axis view of the aortic valve in transesophageal echocardiography indicates the absence of the previously demonstrated echo-free space between the mitral and aortic valves (prosthesis). Arrow points to the aortic tube graft. * pseudoaneurysm in the mitral-aortic intervalvular fibrosa; AO, Aortic tube graft
The mitral-aortic inter valvular fibrosa is an avascular fibrotic region between the aortic non coronary cusp and the anterior mitral leaflet and is susceptible to pseudo aneurysm formation due to mainly, infective endocarditis followed by surgical complications in the presence of native and prosthetic valves.,, Pseudo aneurysm formation may also occur in the presence of an aortic tube graft containing a prosthetic aortic valve. A previous investigation reported a mitral-aortic inter valvular fibrosa pseudo aneurysm due to Brucella melitensis treated with surgery and antibiotics. Surgery is usually recommended because of the possibility of catastrophic events. Accordingly, in the evaluation of patients with a history of the Bentall surgery, the probability of the presence of this complication should be considered.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Zencirkiran Agus H, Atamaner O, Uygur B, Kalkan AK, Ertürk M. Infective endocarditis of a bicuspid aortic valve complicated by septal aneurysm and mitral-aortic intervalvular fibrosa pseudoaneurysm. Turk Kardiyol Dern Ars 2018;46:147-50.