ACA_33_15R4
Heart to Heart Blog Interesting Images
Aneurysm: Sinus of valsalva or ventricular septal? Monish S. Raut, Arun Maheshwari, Sumir Dubey1 Departments of Cardiac Anesthesia and 1Cardiac Surgery, Dharam Vira Heart Center, Sir Ganga Ram Hospital, New Delhi, India
Videos Available on:
www.annals.in Access this article online
Website: www.annals.in PMID: *** DOI: 10.4103/0971-9784.159819 Quick Response Code:
A 37‑year‑old woman presented with a history of shortness of breath on mild exertion. The Transthoracic echocardiographic evaluation suggested severe rheumatic mitral stenosis with a mean gradient of 12 mmHg across the mitral valve. She was referred to our center for mitral valve replacement. After induction of anesthesia, transesophageal echocardiography (TEE) was done before going on cardiopulmonary bypass. TEE was suggestive of severe rheumatic mitral stenosis [Figure 1 and Clip 1] with a mean gradient of 10 mmHg. As the TEE comprehensive examination was done, the mid‑esophageal aortic valve short axis view showed aneurysmal sac of area 1.04 cm2 protruding from right coronary cusp area into the right ventricular cavity [Figure 2 and Clip 2]. The same observations were also made in different TEE views [Figure 3]. In transgastric TEE view, the aneurysmal sac was seen coming into right ventricular outflow tract (RVOT), however, the gradient across RVOT was not significant ruling out any obstruction [Figure 4]. Color Doppler did not show any rupture of aneurysm nor aortic regurgitation. TEE findings were suggestive of the possible sinus of valsalva aneurysm without any other congenital cardiac defects. The surgeon decided to open aortic root after going on bypass. No aneurismal sac was noticed in the right coronary sinus of valsalva. As left atrium was opened for mitral valve replacement, surgeon palpated membranous ventricular septum, which appeared to be saggy and aneurysmally dilated. So it was the membranous ventricular septal aneurysm mimicking as the sinus of valsalva aneurysm on TEE. Septal aneurysm was not surgically altered. The patient was weaned from cardiopulmonary bypass smoothly after mitral valve replacement.
© 2015 Annals of Cardiac Anaesthesia | Published by Wolters Kluwer - Medknow
A membranous interventricular septal aneurysm is an extremely uncommon cardiac anomaly with very few reported incidences in the literature. It is mostly reported in association with congenital heart conditions in 0.3% of cases and association with ventricular septal defects (VSDs) in 19% of cases. [1,2] Majority of cases are congenital in origin,[3,4] and other etiological factors include the spontaneous closure of a preexisting VSD, infections, trauma or idiopathic. [2‑6] Patients with membranous interventricular septal aneurysm may be asymptomatic or may have hemodynamic compromise [4] due to complications like RVOT obstruction, aneurysm rupture, conduction abnormalities, endocarditis, and thromboembolism. The condition is rare and diagnosed usually incidentally.[2,6] Naidu et al. have reported incidental detection of aneurysm of the membranous ventricular septum during echocardiography and confirmed on computed tomography and second case reported by the same author while investigating symptomatic aortic stenosis due to a sclerotic bicuspid valve.[4] Yavuz et al. reported a case of ventricular septal Address for correspondence: Dr. Monish S. Raut, Departments of Cardiac Anesthesia, Dharam Vira Heart Center, Sir Ganga Ram Hospital, Old Rajinder Nagar, New Delhi ‑ 110 060, India. E‑mail: [email protected]
This is an open access article distributed under the terms of the Creative Commons Attribution‑NonCommercial‑ShareAlike 3.0 License, which allows others to remix, tweak, and build upon the work non‑commercially, as long as the author is credited and the new creations are licensed under the identical terms. For reprints contact: [email protected] Cite this article as: Raut MS, Maheshwari A, Dubey S. Aneurysm: Sinus of valsalva or ventricular septal?. Ann Card Anaesth 2015;18:427-9.
427
Raut, et al.: Ventricular septal aneurysm mimicking valsalva aneurysm
Figure 1: Mid-esophageal 4 chamber transesophageal echocardiographic view showing severe rheumatic mitral stenosis
Figure 2: Mid-esophageal aortic valve short axis transesophageal echocardiographic view showing aneurysm from right coronary cusp
Figure 3: Mid-esophageal 5 chamber transesophageal echocardiographic view showing aneurysm
Figure 4: Transgastric transesophageal echocardiographic view showing gradient across right ventricular outflow tract
aneurysm during elective surgery for a calcified bicuspid aortic valve.[2] Linhart and Razi have suggested that a late systolic murmur heard primarily along the left sternal border could give a clue to the diagnosis of aneurysm of the membranous ventricular septum.[7]
evaluation.[1] In the present case, isolated mitral valve replacement was performed without addressing the surgical management of aneurysm due to the potential for an iatrogenic conduction block. No guidelines or recommendations about the management have been advised in the literature. Such patients should be carefully followed and cautioned about the possible complications.
Yavuz et al., suggested surgical correction of such aneurysm can be considered if it is associated with hemodynamic abnormalities and other aneurysm‑related complications.[2] However, Yilmaz et al. advocated preventive surgical intervention to avoid further enlargement and likely complications even in the absence of cardiac symptoms.[8] Patients who have been incidentally diagnosed membranous septal aneurysms should be investigated for associated cardiac anomalies and further diagnostic
428
Financial support and sponsorship Nil. Conflict of interest There are no conflict of interest. REFERENCES 1. Choi M, Jung JI, Lee BY, Kim HR. Ventricular septal
Annals of Cardiac Anaesthesia | Jul-Sep-2015 | Vol 18 | Issue 3
Raut, et al.: Ventricular septal aneurysm mimicking valsalva aneurysm
2. 3. 4.
5.
aneurysms in adults: Findings of cardiac CT images and correlation with clinical features. Acta Radiol 2011;52:619‑23. Yavuz S, Eris C, Goncu T, Sezen M, Ata Y, Turk T. An incidental aneurysm of the interventricular membranous septum. Arch Iran Med 2010;13:363‑4. Edelstein J, Charms BL. Ventricular septal aneurysms. A report of two cases. Circulation 1965;32:981‑4. Naidu A, Ricketts M, Goela A, Shoemaker G, Li S. Incidental discovery of a membranous ventricular septal aneurysm in two dissimilar patients. Case Rep Cardiol 2012;2012:324326 Jain AC, Rosenthal R. Aneurysm of the membranous
Annals of Cardiac Anaesthesia | Jul-Sep-2015 | Vol 18 | Issue 3
ventricular septum. Br Heart J 1967;29:60‑3. 6. Espinoza J, Kalache K, Gonçalves LF, L ee W, Chaiworapongsa T, Schoen ML, et al. Prenatal diagnosis of membranous ventricular septal aneurysms and their association with absence of atrioventricular valve offsetting. Ultrasound Obstet Gynaecol 2004;24:787‑92. 7. Linhart JW, Razi B. Late systolic murmur: A clue to the diagnosis of aneurysm of the membranous ventricular septum. Chest 1971;60:283‑6. 8. Yilmaz AT1, Ozal E, Arslan M, Tatar H, Oztürk OY. Aneurysm of the membranous septum in adult patients with perimembranous ventricular septal defect. Eur J Cardiothorac Surg 1997;11:307-11.
429
Heart to Heart Blog Interesting Images
Aneurysm: Sinus of valsalva or ventricular septal? Monish S. Raut, Arun Maheshwari, Sumir Dubey1 Departments of Cardiac Anesthesia and 1Cardiac Surgery, Dharam Vira Heart Center, Sir Ganga Ram Hospital, New Delhi, India
Videos Available on:
www.annals.in Access this article online
Website: www.annals.in PMID: *** DOI: 10.4103/0971-9784.159819 Quick Response Code:
A 37‑year‑old woman presented with a history of shortness of breath on mild exertion. The Transthoracic echocardiographic evaluation suggested severe rheumatic mitral stenosis with a mean gradient of 12 mmHg across the mitral valve. She was referred to our center for mitral valve replacement. After induction of anesthesia, transesophageal echocardiography (TEE) was done before going on cardiopulmonary bypass. TEE was suggestive of severe rheumatic mitral stenosis [Figure 1 and Clip 1] with a mean gradient of 10 mmHg. As the TEE comprehensive examination was done, the mid‑esophageal aortic valve short axis view showed aneurysmal sac of area 1.04 cm2 protruding from right coronary cusp area into the right ventricular cavity [Figure 2 and Clip 2]. The same observations were also made in different TEE views [Figure 3]. In transgastric TEE view, the aneurysmal sac was seen coming into right ventricular outflow tract (RVOT), however, the gradient across RVOT was not significant ruling out any obstruction [Figure 4]. Color Doppler did not show any rupture of aneurysm nor aortic regurgitation. TEE findings were suggestive of the possible sinus of valsalva aneurysm without any other congenital cardiac defects. The surgeon decided to open aortic root after going on bypass. No aneurismal sac was noticed in the right coronary sinus of valsalva. As left atrium was opened for mitral valve replacement, surgeon palpated membranous ventricular septum, which appeared to be saggy and aneurysmally dilated. So it was the membranous ventricular septal aneurysm mimicking as the sinus of valsalva aneurysm on TEE. Septal aneurysm was not surgically altered. The patient was weaned from cardiopulmonary bypass smoothly after mitral valve replacement.
© 2015 Annals of Cardiac Anaesthesia | Published by Wolters Kluwer - Medknow
A membranous interventricular septal aneurysm is an extremely uncommon cardiac anomaly with very few reported incidences in the literature. It is mostly reported in association with congenital heart conditions in 0.3% of cases and association with ventricular septal defects (VSDs) in 19% of cases. [1,2] Majority of cases are congenital in origin,[3,4] and other etiological factors include the spontaneous closure of a preexisting VSD, infections, trauma or idiopathic. [2‑6] Patients with membranous interventricular septal aneurysm may be asymptomatic or may have hemodynamic compromise [4] due to complications like RVOT obstruction, aneurysm rupture, conduction abnormalities, endocarditis, and thromboembolism. The condition is rare and diagnosed usually incidentally.[2,6] Naidu et al. have reported incidental detection of aneurysm of the membranous ventricular septum during echocardiography and confirmed on computed tomography and second case reported by the same author while investigating symptomatic aortic stenosis due to a sclerotic bicuspid valve.[4] Yavuz et al. reported a case of ventricular septal Address for correspondence: Dr. Monish S. Raut, Departments of Cardiac Anesthesia, Dharam Vira Heart Center, Sir Ganga Ram Hospital, Old Rajinder Nagar, New Delhi ‑ 110 060, India. E‑mail: [email protected]
This is an open access article distributed under the terms of the Creative Commons Attribution‑NonCommercial‑ShareAlike 3.0 License, which allows others to remix, tweak, and build upon the work non‑commercially, as long as the author is credited and the new creations are licensed under the identical terms. For reprints contact: [email protected] Cite this article as: Raut MS, Maheshwari A, Dubey S. Aneurysm: Sinus of valsalva or ventricular septal?. Ann Card Anaesth 2015;18:427-9.
427
Raut, et al.: Ventricular septal aneurysm mimicking valsalva aneurysm
Figure 1: Mid-esophageal 4 chamber transesophageal echocardiographic view showing severe rheumatic mitral stenosis
Figure 2: Mid-esophageal aortic valve short axis transesophageal echocardiographic view showing aneurysm from right coronary cusp
Figure 3: Mid-esophageal 5 chamber transesophageal echocardiographic view showing aneurysm
Figure 4: Transgastric transesophageal echocardiographic view showing gradient across right ventricular outflow tract
aneurysm during elective surgery for a calcified bicuspid aortic valve.[2] Linhart and Razi have suggested that a late systolic murmur heard primarily along the left sternal border could give a clue to the diagnosis of aneurysm of the membranous ventricular septum.[7]
evaluation.[1] In the present case, isolated mitral valve replacement was performed without addressing the surgical management of aneurysm due to the potential for an iatrogenic conduction block. No guidelines or recommendations about the management have been advised in the literature. Such patients should be carefully followed and cautioned about the possible complications.
Yavuz et al., suggested surgical correction of such aneurysm can be considered if it is associated with hemodynamic abnormalities and other aneurysm‑related complications.[2] However, Yilmaz et al. advocated preventive surgical intervention to avoid further enlargement and likely complications even in the absence of cardiac symptoms.[8] Patients who have been incidentally diagnosed membranous septal aneurysms should be investigated for associated cardiac anomalies and further diagnostic
428
Financial support and sponsorship Nil. Conflict of interest There are no conflict of interest. REFERENCES 1. Choi M, Jung JI, Lee BY, Kim HR. Ventricular septal
Annals of Cardiac Anaesthesia | Jul-Sep-2015 | Vol 18 | Issue 3
Raut, et al.: Ventricular septal aneurysm mimicking valsalva aneurysm
2. 3. 4.
5.
aneurysms in adults: Findings of cardiac CT images and correlation with clinical features. Acta Radiol 2011;52:619‑23. Yavuz S, Eris C, Goncu T, Sezen M, Ata Y, Turk T. An incidental aneurysm of the interventricular membranous septum. Arch Iran Med 2010;13:363‑4. Edelstein J, Charms BL. Ventricular septal aneurysms. A report of two cases. Circulation 1965;32:981‑4. Naidu A, Ricketts M, Goela A, Shoemaker G, Li S. Incidental discovery of a membranous ventricular septal aneurysm in two dissimilar patients. Case Rep Cardiol 2012;2012:324326 Jain AC, Rosenthal R. Aneurysm of the membranous
Annals of Cardiac Anaesthesia | Jul-Sep-2015 | Vol 18 | Issue 3
ventricular septum. Br Heart J 1967;29:60‑3. 6. Espinoza J, Kalache K, Gonçalves LF, L ee W, Chaiworapongsa T, Schoen ML, et al. Prenatal diagnosis of membranous ventricular septal aneurysms and their association with absence of atrioventricular valve offsetting. Ultrasound Obstet Gynaecol 2004;24:787‑92. 7. Linhart JW, Razi B. Late systolic murmur: A clue to the diagnosis of aneurysm of the membranous ventricular septum. Chest 1971;60:283‑6. 8. Yilmaz AT1, Ozal E, Arslan M, Tatar H, Oztürk OY. Aneurysm of the membranous septum in adult patients with perimembranous ventricular septal defect. Eur J Cardiothorac Surg 1997;11:307-11.
429
