Pseudoaneurysms of the left ventricular outflow tract are rare but potentially very serious complication of aortic valve replacement, composite aortic root replacement, and infective endocarditis.Because of relative rarity of this condition, very little is known of the natural history of these and treatment guidelines are empirical.The exception would be the pseudoaneurysm due to infective endocarditis, when the treatment guidelines are based on the infective endocarditis itself.
Felix Rogers, D.O., is requesting that members of the Michigan Society of Echocardiography pool their information about these left ventricular outflow tract pseudoaneurysms.The MSE can establish a registry which may allow us to compile a sufficient database to learn more about the frequency, natural history, and treatment recommendations for this condition.
Pseudoaneurysms that follow aortic valve replacement typically occur in the potential space between the aortic valve and the base of the anterior mitral leaflet.Over the years, this has variously been called the mitral-aortic intervalvular fibrosa, pseudoaneurysm of the intervalvular annulus fibrosa or LVOT pseudoaneurysms.These are best detected by CT angiography.The attached figure shows an example of a pseudoaneurysm of the mitral-aortic intervalvular fibrosa taken from a case report by Tahir Tak, M.D., Ph.D. published in Clinical Medicine and Research, 2003; 1(1): 49-52.
If you are able to submit one or more cases to our registry, it would be helpful if you could send a CD of the echocardiogram and where available the CT angiogram as well.In addition, please complete the description of patient characteristic found on table I.
Submit all of this information to:
Felix J. Rogers, D.O., Downriver Cardiology Consultants 5400 Fort St., Suite 200 Trenton, Michigan 48183.
TABLE 1: Characteristics of patients with LVOT pseudoaneurysm after prosthetic aortic valve replacement.
Indication for valve replacement
Suture technique (horizontal mattress, sutures with pledgets, etc.)
Transthoracic echocardiography (dated)
Transesophageal echocardiography (date)
Time of aortic valve replacement
Location of pseudoaneurysm in LVOT (noncoronary, left coronary)
Thrombosis (none, partial, total)
Neck diameter in mm
Size of pseudoaneurysm in mm3
Length of follow up after demonstration of pseudoaneurysm
Pseudoaneurysm of the Mitral-aortic Intervalvular Fibrosa: An Update
In February 2010, I issued a call for cases of pseudoaneurysm of the mitral-aortic intervalvular fibrosa (MAIVF).Now, one year later, I think it is appropriate to suspend the project.First of all, the condition is so rare that only one other case was submitted to add to my own collection.Secondly, a comprehensive review article was published in the Journal of the American Society of Echocardiography in October 2010.That article reviewed 88 patients from the English-language literature published from 1966 to the end of 2009.The author added his own case for a total of 89 cases.Such a review renders our efforts unnecessary.
Here is what they report: pseudoaneurysm of the mitral-aortic intervalvular fibrosa (P-MAIVF) is a rare condition that has been reported to occur following endocarditis and surgical trauma.This is an entity that occurs in the interannular zone between the mitral and aortic valves and its communication with the left ventricular outflow tract between the left coronary or non-coronary aortic cusp and the anterior leaflet of the mitral valve.
Three-quarters of patients present with symptoms and signs of infection, chest pain, heart failure or shortness of breath and cerebrovascular accidents.The age range is between 3 months and 90 years.About half of the patients had prosthetic aortic valves and the clear majority of those valves were mechanical as opposed to bioprosthetic.Of the patients with this complication and native valves, 33% of those were bicuspid valves.
Active or prior endocarditis was present in 64 patients and there was no endocarditis in 19.Surgery is considered to be the treatment of choice.It was performed in 68 patients.Fifty-six had aortic valve replacement with P-MAIVF repair.Ten patients had P-MAIVF repair with no valve surgery and one had P-MAIVF and mitral valve repair.
Of the 8 patients who did not undergo surgery, one went to hospice for palliative care.In one patient with four year follow up, the pseudoaneurysm increased in size and in the other two there were no changes at 10 month and 3 year follow up.(Of my patients, the first had spontaneous thrombosis and resolution of the P-MAIVF and the other went to repeat mitral valve surgery because of infective endocarditis.)Fourteen patients died: 3 from P-MAIVF rupture into the pericardium, 3 from sepsis, and 6 post operatively.One had an unrelated drug overdose.One patient with no medical history had sudden death and autopsy showed changes consistent with compression of the left circumflex artery. (We saw a case of compression of the circumflex by P-MAIVF at the Echo in the Slopes meeting this past January.)
Theodore M. Batzer, M.D. of Manistee, Michigan submitted a great case for our series.A still frame of that study is posted here as figure 1.
Felix J. Rogers, D.O.
FIGURE 1:Pseudoaneurysm of the mitral aortic intervalvular fibrosa.The patient had replacement of the aortic valve with a bioprosthetic device in December 2001 with mitral valve repair.He has had several significant infections including septic risk (staph aureus about 2005) and the infected total knee arthroplasty with enterococcus faecalis (not VRE) in 2006 with a subsequent re-do total knee arthroplasty that year.