case report Wien Klin Wochenschr DOI 10.1007/s00508-015-0737-3

Giant left ventricular aneurysm after recurrent mitral valve replacement Çağin Mustafa Üreyen · Şakir Arslan · Isa Öner Yüksel · Cem Yunus Baş

Received: 18 November 2014 / Accepted: 19 January 2015 © Springer-Verlag Wien 2015

Summary  Left ventricular pseudoaneurysm after mitral valve replacement has been reported in various studies; however, as far as we know, a true aneurysm after redo mitral valve replacement has not been reported in any article yet. We herein present a patient who developed a true aneurysm and atrioventricular complete block after third surgery of mitral valve. DDD pacemaker was implanted, albeit the patient refused reoperation for aneurysmectomy. Keywords  Mitral valve replacement  · Left ventricular aneurysm · Reoperation

Introduction Complications after mitral valve replacement (MVR) are quite uncommon; however, reoperations have a higher mortality and morbidity rates. Left ventricular pseudoaneurysm has been presented as a rare complication of MVR; however, to the best of our knowledge, a true aneurysm after reoperation of MVR has not been published yet in English medical literature.

Case report A 29-year-old woman having MVR 10 years ago admitted to outpatient clinic with exertional dyspnea after 2 weeks of delivery. A mobile 2-cm-sized thrombus was detected C. Y. Baş, MD () · Ç. M. Üreyen, MD · Ş. Arslan, MD · I. Ö. Yüksel, MD Antalya Education and Research Hospital, Department of Cardiology, Varlik mah. Kazimkarabekir Caddesi, Soğuksu, 07100 Muratpaşa, Antalya, Turkey e-mail: [email protected]

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on echocardiography, while International normalized ratio (INR) was 1.57 (Fig.  1). Transmitral diastolic peak and mean gradients were 21 and 11 mmHg, respectively. The patient was hospitalized and anticoagulated with intravenous unfractioned heparin and consulted with cardiovascular surgeons regarding MVR. After taking the consent of the patient, thrombosed mitral prosthesis was replaced with another metallic prosthesis. However, moderate-to-severe paravalvular mitral regurgitation was ascertained by echocardiography after 2 days of the operation even though there was no paravalvular leak during surgery confirmed with intraoperative transesophageal echocardiography (Fig.  2). The patient was reoperated, and paravalvular leak was completely repaired. However, the patient re-admitted to outpatient clinic with presyncope and exertional dyspnea lasting for 6 days after 2 weeks of reoperation. Atrioventricular (AV) complete block was detected on electrocardiography (ECG) with an heart rate of 51/min and narrow QRS. Patient was recommended to be hospitalized, and permanent pacemaker implantation was proposed. The patient refused hospitalization. Two weeks later, patient applied to emergency department with syncope, and her ECG was still denoting AV complete block. The patient was hospitalized; and she admitted permanent pacemaker implantation, and DDD pacemaker was implanted. Ejection fraction (EF) was 55 %, and mitral prosthesis was well functioning. One month later, patient visited the outpatient clinic again with exertional dyspnea and orthopnea. Initially, pacemaker malfunction was suspected but pacemaker was functioning well, the leads were all in correct position and 100 % atrial sensing and ventricular pacing were detected. Echocardiography was performed, and a huge aneurysm involving basal segments of both lateral and posterior walls was demonstrated (Figs. 3 and 4). EF was calculated 35 % with modified Simpson method. There was no perforation of the left ventricle, and the neck of aneurysm was broad enough. Hospitalization and opera-

Giant left ventricular aneurysm after recurrent mitral valve replacement  

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case report Fig. 1  Mobile thrombus on prosthetic mitral valve

Fig. 2  Moderate to severe paravalvular mitral regurgitation

tion of the aneurysm were recommended. However, the patient rejected surgery, and she was prescribed perindopril, carvedilol, spironolactone, and furosemide. Three months later, the patient was examined at outpatient clinic. She was having New York Heart Association (NYHA) class 2 symptoms and still rejecting operation.

Discussion In literature, left ventricular pseudoaneurysm formation as a late complication after MVR was published in several case reports [1–3]. Pseudoaneurysm is a rare complica-

tion after MVR, which may be fatal unless early surgical correction is done. This complication occurs in 0.02–2 % of MVRs. Predisposing factors are resection of posterior leaflet, extensive annular decalcification, insertion of an oversized prosthesis, and redo MVR [4]. However, to the best of our knowledge, this is the first case of left ventricular true aneurysm formation after recurrent MVR in English medical literature. The intact ventricular wall of aneurysm was easily demonstrated by echocardiography, and broad neck of aneurysm was depicted. The probable pathophysiology and predisposing factors of true aneurysm in our case may be similar with predisposing factors and mechanism of pseudoaneurysm formation after

2   Giant left ventricular aneurysm after recurrent mitral valve replacement

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case report Fig. 3  Aneurysm of basal segment of lateral wall

Fig. 4  Aneurysm of basal segment of posterior wall

MVR. It was the third mitral valve operation of the patient (redo MVR), and heavily calcified annulus was decalcified while thrombosed prosthesis was being replaced. These could be the possible causes of true aneurysm formation in our case. However, more cases are needed to elucidate the predisposing factors explicitly.

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Informed consent  Informed consent was obtained from patient for being included in the study. Conflict of interest  The authors declare that there is no conflict of interest.

Giant left ventricular aneurysm after recurrent mitral valve replacement  

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case report References 1. Biyikoglu SF, Guray Y, Turkvatan A, Boyaci A, Katircioglu F. A serious complication late after mitral valve replacement: left ventricular rupture with pseudoaneurysm. J Am Soc Echocardiogr. 2008;21:1178.e1–3. 2. Min SK, Sir JJ, Nah JC, Kim YL. Successful resection of a giant left ventricular pseudoaneurysm developed later after mitral valve replacement. J Korean Med Sci. 2010;25:1080–2.

3. Ikegami H, Mc Carty PM. Internal repair of left ventricular pseudoaneurysm late after mitral valve replacement. Interact Cardiovasc Thorac Surg. 2014;18(1):128–9. 4. Hirasawa Y, Tadamasa M, Sawamura T, Takiya H. Giant left ventricular pseudoaneurysm after mitral valve replacement and myocardial infarction. Ann Thorac Surg. 2004;78:1823–5.

4   Giant left ventricular aneurysm after recurrent mitral valve replacement

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Giant left ventricular aneurysm after recurrent mitral valve replacement.

Left ventricular pseudoaneurysm after mitral valve replacement has been reported in various studies; however, as far as we know, a true aneurysm after...
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