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Case Study
Left ventricular pseudoaneurysm following balloon mitral valvuloplasty
Asian Cardiovascular & Thoracic Annals 0(0) 1–3 ß The Author(s) 2014 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav DOI: 10.1177/0218492314529135 aan.sagepub.com
Rajpal K Abhaichand, Kalpathi Ananthanarayanan Sambasivam and Bivin Wilson
Abstract Balloon mitral valvotomy is a commonly performed procedure for mitral stenosis. This procedure can lead to complications such as left ventricular perforation with tamponade, mitral regurgitation and stroke. Here we report a case of left ventricular pseudoaneurysm following balloon mitral valvotomy. It was a consequence of adherent pericardium secondary to open mitral valvotomy performed earlier. It was surgically corrected by pseudoaneurysm repair and mitral valve replacement. We believe that this is the first such reported case.
Keywords Aneurysm, false, balloon valvuloplasty, left ventricle, mitral valve stenosis, rheumatic heart disease
Introduction Balloon mitral valvuloplasty (BMV) is an accepted treatment for rheumatic mitral stenosis. This form of therapy has evolved considerably since its inception in 1982.1 We currently use a Jomiva balloon catheter over a 0.035-inch, 200-cm back-up Meier wire (Boston Scientific Corporation) which is a well-described and less expensive technique.2 The incidence of complications of this procedure, such as left ventricular (LV) perforation with tamponade, mitral regurgitation, and stroke, varies from 7% to 9%. We report an unusual complication, a pseudoaneurysm of the LV, which presented 4 weeks after the procedure.
Case report A 44-year-old lady presented to our institute with exertional dyspnea New York Heart Association class III of 3 months duration. She has undergone open mitral commissurotomy and thrombectomy for severe mitral stenosis with a pliable valve and left atrial thrombus 14 years before her current presentation. She was in atrial fibrillation. Transthoracic and transesophageal echocardiography revealed severe mitral restenosis, a pliable valve with a Wilkins score of 6, and the absence of mitral regurgitation and left atrial thrombus. She underwent an uneventful BMV with sequential
dilatations using a 24 mm 4-cm and a 25 mm 4-cm Jomiva balloon catheter (Figure 1). Echocardiography following the procedure showed an increase in the mitral valve orifice from 1 to 1.5 cm2 with no mitral regurgitation and a fall in the mean pulmonary artery pressure from 48 to 40 mm Hg. Three weeks after the procedure, she presented with epigastric discomfort and lack of appetite, for which she was treated symptomatically. A week later, she returned with worsening of these symptoms and dyspnea at rest. Examination revealed congestive cardiac failure and a pansystolic murmur. Transthoracic echocardiography demonstrated a 5 8-mm expansile pseudoaneurysm of the LV apex, with a narrow neck. Color and pulsed-wave Doppler revealed systolic flow into the aneurysm and diastolic flow across its neck into the ventricular cavity (Figure 2). The patient underwent excision and repair of the LV pseudoaneurysm with mitral valve replacement, after which she remained asymptomatic.
Department of Cardiology, GKNM Hospital, Coimbatore, India Corresponding author: Bivin Wilson, Department of Cardiology, GKNM Hospital, Post Box No. 6327, Nethaji Road, Pappanaickenpalayam, Coimbatore 641037, Tamilnadu, India. Email: [email protected]
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[1–3] [PREPRINTER stage]
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Asian Cardiovascular & Thoracic Annals 0(0)
Discussion The complications of BMV are well described. Cardiac perforation and tamponade was reported in 0.5% to 1.2% of patients in a large registry of BMV using the Inoue balloon technique.3 In another large series of patients who underwent BMV using the Jomiva balloon catheter, 0.8% had cardiac perforation, of which 0.1% was LV perforation.2 LV pseudoaneurysm was not reported in either of these studies. LV aneurysms can be either true aneurysms or pseudoaneurysms, and are of varied etiology and located in various parts of the ventricle. Pseudoaneurysms usually have a narrow neck. They usually result from rupture of the
Figure 1. Cineangiogram showing the inflated Jomiva balloon over the Meier wire across the mitral valve orifice. The arrowheads delineate calcification in the wall of the left atrium.
ventricular free wall contained by overlying adherent pericardium. The most common causes are myocardial infarction and cardiac surgery.4 Diagnosis can be difficult because the patients are often either asymptomatic or present with nonspecific symptoms. In a large series of pseudoaneurysms, 48% of cases were diagnosed incidentally and the remaining cases presented with congestive cardiac failure, arrhythmia, or systemic embolism.5 The risk of rupture is 30% to 45%.6 Transesophageal echocardiography is an excellent tool for diagnosis of LV pseudoaneurysms. Color Doppler and pulsed-wave Doppler help in early recognition, which is very crucial for survival.7 Other diagnostic modalities include LV angiography, computed tomography, and cardiac magnetic resonance imaging. Surgical closure is the treatment of choice for LV pseudoaneurysms, and if left untreated, they may result in rupture. However, Sakai and colleagues,8 in a series of LV pseudoaneurysms following mitral valve surgery, treated 7 of 8 patients medically without any complications up to 11 years. In our case, subsequent to the initial surgical procedure of open mitral commissurotomy and thrombectomy, significant pericardial adhesions and obliteration of the pericardial space are likely to have occurred. During BMV, a small wire-induced perforation of the LV apex, which would have otherwise led to cardiac tamponade, remained contained without any immediate consequence as a result of the adherent thickened pericardium. The LV rent continuously exposed the adherent pericardium to intracardiac pressures, leading to the formation of a pseudoaneurysm over a period of time. Oral anticoagulation therapy for atrial fibrillation would also have contributed to the problem.
Figure 2. Color and pulse wave doppler showing flow across neck of pseudoaneurysm.
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(AAN)
[1–3] [PREPRINTER stage]
Abhaichand et al.
3
Pseudoaneurysms of the LV following mitral valve replacement, aortic valve replacement, and even balloon aortic valvuloplasty have been reported. However, we have described a case of pseudoaneurysm presenting 4 weeks after BMV, and we believe it is the first such reported case. Following an over-the-wire technique of BMV, apart from the known complications of mitral regurgitation, LV perforation, and stroke, the rare occurrence of LV pseudoaneurysm should also be kept in mind, especially in patients who have undergone open mitral commissurotomy earlier. Early recognition and corrective surgery is considered crucial for survival. Funding This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.
2.
3.
4. 5.
6.
7.
Conflicts of interest statement None declared. 8.
References 1. Inoue K, Owaki T, Nakamura T, Kitamura F and Miyamoto N. Clinical application of transvenous mitral
commissurotomy by a new balloon catheter. J Thorac Cardiovasc Surg 1984; 87: 394–402. Joseph G1, Chandy S, George P, et al. Evaluation of a simplified transseptal mitral valvuloplasty technique using over-the-wire single balloons and complementary femoral and jugular venous approaches in 1,407 consecutive patients. J Invasive Cardiol 2005; 17: 132–138. Complications and mortality of percutaneous balloon mitral commissurotomy. A report from the National Heart, Lung, and Blood Institute Balloon Valvuloplasty Registry. Circulation 1992; 85: 2014–2024. Mackenzie JW and Lemole GM. Pseudoaneurysm of the left ventricle. Tex Heart Inst J 1994; 21: 296–301. Yeo TC, Malouf JF, Oh JK and Seward JB. Clinical profile and outcome in 52 patients with cardiac pseudoaneurysm. Ann Intern Med 1998; 128: 299–305. Vlodaver Z, Coe JI and Edwards JE. True and false left ventricular aneurysms. Propensity for the latter to rupture. Circulation 1975; 51: 567–572. Grube E, Redel D and Janson R. Non-invasive diagnosis of a false left ventricular aneurysm by echocardiography and pulsed Doppler echocardiography. Br Heart J 1980; 43: 232–236. Sakai K, Nakamura K, Ishizuka N, et al. Echocardiographic findings and clinical features of left ventricular pseudoaneurysm after mitral valve replacement. Am Heart J 1992; 124: 975–982.
Downloaded from aan.sagepub.com at UNIVERSITE DE MONTREAL on August 18, 2015
(AAN)
[1–3] [PREPRINTER stage]
Case Study
Left ventricular pseudoaneurysm following balloon mitral valvuloplasty
Asian Cardiovascular & Thoracic Annals 0(0) 1–3 ß The Author(s) 2014 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav DOI: 10.1177/0218492314529135 aan.sagepub.com
Rajpal K Abhaichand, Kalpathi Ananthanarayanan Sambasivam and Bivin Wilson
Abstract Balloon mitral valvotomy is a commonly performed procedure for mitral stenosis. This procedure can lead to complications such as left ventricular perforation with tamponade, mitral regurgitation and stroke. Here we report a case of left ventricular pseudoaneurysm following balloon mitral valvotomy. It was a consequence of adherent pericardium secondary to open mitral valvotomy performed earlier. It was surgically corrected by pseudoaneurysm repair and mitral valve replacement. We believe that this is the first such reported case.
Keywords Aneurysm, false, balloon valvuloplasty, left ventricle, mitral valve stenosis, rheumatic heart disease
Introduction Balloon mitral valvuloplasty (BMV) is an accepted treatment for rheumatic mitral stenosis. This form of therapy has evolved considerably since its inception in 1982.1 We currently use a Jomiva balloon catheter over a 0.035-inch, 200-cm back-up Meier wire (Boston Scientific Corporation) which is a well-described and less expensive technique.2 The incidence of complications of this procedure, such as left ventricular (LV) perforation with tamponade, mitral regurgitation, and stroke, varies from 7% to 9%. We report an unusual complication, a pseudoaneurysm of the LV, which presented 4 weeks after the procedure.
Case report A 44-year-old lady presented to our institute with exertional dyspnea New York Heart Association class III of 3 months duration. She has undergone open mitral commissurotomy and thrombectomy for severe mitral stenosis with a pliable valve and left atrial thrombus 14 years before her current presentation. She was in atrial fibrillation. Transthoracic and transesophageal echocardiography revealed severe mitral restenosis, a pliable valve with a Wilkins score of 6, and the absence of mitral regurgitation and left atrial thrombus. She underwent an uneventful BMV with sequential
dilatations using a 24 mm 4-cm and a 25 mm 4-cm Jomiva balloon catheter (Figure 1). Echocardiography following the procedure showed an increase in the mitral valve orifice from 1 to 1.5 cm2 with no mitral regurgitation and a fall in the mean pulmonary artery pressure from 48 to 40 mm Hg. Three weeks after the procedure, she presented with epigastric discomfort and lack of appetite, for which she was treated symptomatically. A week later, she returned with worsening of these symptoms and dyspnea at rest. Examination revealed congestive cardiac failure and a pansystolic murmur. Transthoracic echocardiography demonstrated a 5 8-mm expansile pseudoaneurysm of the LV apex, with a narrow neck. Color and pulsed-wave Doppler revealed systolic flow into the aneurysm and diastolic flow across its neck into the ventricular cavity (Figure 2). The patient underwent excision and repair of the LV pseudoaneurysm with mitral valve replacement, after which she remained asymptomatic.
Department of Cardiology, GKNM Hospital, Coimbatore, India Corresponding author: Bivin Wilson, Department of Cardiology, GKNM Hospital, Post Box No. 6327, Nethaji Road, Pappanaickenpalayam, Coimbatore 641037, Tamilnadu, India. Email: [email protected]
Downloaded from aan.sagepub.com at UNIVERSITE DE MONTREAL on August 18, 2015
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(AAN)
[1–3] [PREPRINTER stage]
2
Asian Cardiovascular & Thoracic Annals 0(0)
Discussion The complications of BMV are well described. Cardiac perforation and tamponade was reported in 0.5% to 1.2% of patients in a large registry of BMV using the Inoue balloon technique.3 In another large series of patients who underwent BMV using the Jomiva balloon catheter, 0.8% had cardiac perforation, of which 0.1% was LV perforation.2 LV pseudoaneurysm was not reported in either of these studies. LV aneurysms can be either true aneurysms or pseudoaneurysms, and are of varied etiology and located in various parts of the ventricle. Pseudoaneurysms usually have a narrow neck. They usually result from rupture of the
Figure 1. Cineangiogram showing the inflated Jomiva balloon over the Meier wire across the mitral valve orifice. The arrowheads delineate calcification in the wall of the left atrium.
ventricular free wall contained by overlying adherent pericardium. The most common causes are myocardial infarction and cardiac surgery.4 Diagnosis can be difficult because the patients are often either asymptomatic or present with nonspecific symptoms. In a large series of pseudoaneurysms, 48% of cases were diagnosed incidentally and the remaining cases presented with congestive cardiac failure, arrhythmia, or systemic embolism.5 The risk of rupture is 30% to 45%.6 Transesophageal echocardiography is an excellent tool for diagnosis of LV pseudoaneurysms. Color Doppler and pulsed-wave Doppler help in early recognition, which is very crucial for survival.7 Other diagnostic modalities include LV angiography, computed tomography, and cardiac magnetic resonance imaging. Surgical closure is the treatment of choice for LV pseudoaneurysms, and if left untreated, they may result in rupture. However, Sakai and colleagues,8 in a series of LV pseudoaneurysms following mitral valve surgery, treated 7 of 8 patients medically without any complications up to 11 years. In our case, subsequent to the initial surgical procedure of open mitral commissurotomy and thrombectomy, significant pericardial adhesions and obliteration of the pericardial space are likely to have occurred. During BMV, a small wire-induced perforation of the LV apex, which would have otherwise led to cardiac tamponade, remained contained without any immediate consequence as a result of the adherent thickened pericardium. The LV rent continuously exposed the adherent pericardium to intracardiac pressures, leading to the formation of a pseudoaneurysm over a period of time. Oral anticoagulation therapy for atrial fibrillation would also have contributed to the problem.
Figure 2. Color and pulse wave doppler showing flow across neck of pseudoaneurysm.
Downloaded from aan.sagepub.com at UNIVERSITE DE MONTREAL on August 18, 2015
XML Template (2014) [12.3.2014–2:43pm] //blrnas3/cenpro/ApplicationFiles/Journals/SAGE/3B2/AANJ/Vol00000/140056/APPFile/SG-AANJ140056.3d
(AAN)
[1–3] [PREPRINTER stage]
Abhaichand et al.
3
Pseudoaneurysms of the LV following mitral valve replacement, aortic valve replacement, and even balloon aortic valvuloplasty have been reported. However, we have described a case of pseudoaneurysm presenting 4 weeks after BMV, and we believe it is the first such reported case. Following an over-the-wire technique of BMV, apart from the known complications of mitral regurgitation, LV perforation, and stroke, the rare occurrence of LV pseudoaneurysm should also be kept in mind, especially in patients who have undergone open mitral commissurotomy earlier. Early recognition and corrective surgery is considered crucial for survival. Funding This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.
2.
3.
4. 5.
6.
7.
Conflicts of interest statement None declared. 8.
References 1. Inoue K, Owaki T, Nakamura T, Kitamura F and Miyamoto N. Clinical application of transvenous mitral
commissurotomy by a new balloon catheter. J Thorac Cardiovasc Surg 1984; 87: 394–402. Joseph G1, Chandy S, George P, et al. Evaluation of a simplified transseptal mitral valvuloplasty technique using over-the-wire single balloons and complementary femoral and jugular venous approaches in 1,407 consecutive patients. J Invasive Cardiol 2005; 17: 132–138. Complications and mortality of percutaneous balloon mitral commissurotomy. A report from the National Heart, Lung, and Blood Institute Balloon Valvuloplasty Registry. Circulation 1992; 85: 2014–2024. Mackenzie JW and Lemole GM. Pseudoaneurysm of the left ventricle. Tex Heart Inst J 1994; 21: 296–301. Yeo TC, Malouf JF, Oh JK and Seward JB. Clinical profile and outcome in 52 patients with cardiac pseudoaneurysm. Ann Intern Med 1998; 128: 299–305. Vlodaver Z, Coe JI and Edwards JE. True and false left ventricular aneurysms. Propensity for the latter to rupture. Circulation 1975; 51: 567–572. Grube E, Redel D and Janson R. Non-invasive diagnosis of a false left ventricular aneurysm by echocardiography and pulsed Doppler echocardiography. Br Heart J 1980; 43: 232–236. Sakai K, Nakamura K, Ishizuka N, et al. Echocardiographic findings and clinical features of left ventricular pseudoaneurysm after mitral valve replacement. Am Heart J 1992; 124: 975–982.
Downloaded from aan.sagepub.com at UNIVERSITE DE MONTREAL on August 18, 2015
