Endocarditis: Intervalvular Fibrosa

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Circulation. 1992 Aug;86(2):353-62.
Transesophageal echocardiographic recognition of subaortic complications in aortic valve endocarditis. Clinical and surgical implications.
Karalis DG, Bansal RC, Hauck AJ, Ross JJ Jr, Applegate PM, Jutzy KR, Mintz GS, Chandrasekaran K.
Department of Internal Medicine (Cardiology) Hahnemann University, Philadelphia, Pa.

BACKGROUND. Secondary involvement of the mitral-aortic intervalvular fibrosa and the anterior mitral leaflet (subaortic structures) can occur in patients with aortic valve endocarditis. The secondary involvement of these structures occurs as a result of direct extension of the infection from the aortic valve or as a result of an infected aortic regurgitant jet striking the ventricular surfaces of the mitral-aortic intervalvular fibrosa and the anterior mitral leaflet. The abscess of mitral-aortic intervalvular fibrosa can expand to form an aneurysm. Subsequently, this mitral-aortic intervalvular fibrosa aneurysm can develop a perforation and communicate with the left atrium, resulting in the systolic regurgitation of blood from the left ventricular outflow tract into the left atrium. Secondary infection can also occur on the ventricular surface of the anterior mitral leaflet and result in the formation of an aneurysm or perforation of anterior mitral leaflet. METHODS AND RESULTS. This study examines the utility of transesophageal echocardiography in the detection of these subaortic complications in 55 consecutive patients with aortic valve endocarditis. A total of 24 patients (44%) had involvement of subaortic structures, including four with an abscess in the mitral-aortic intervalvular fibrosa, four with mitral-aortic intervalvular fibrosa aneurysm, seven with perforation of the mitral-aortic intervalvular fibrosa with communication into the left atrium, two with an aneurysm of the anterior mitral leaflet, and seven with perforation of the anterior mitral leaflet. The transesophageal echocardiographic findings were confirmed at surgery in 20 patients and at necropsy in two. By comparison, transthoracic echocardiography visualized these lesions in five of 24 patients (21%), including none of four with mitral-aortic intervalvular fibrosa abscesses, two of four with mitral-aortic intervalvular fibrosa aneurysms, one of seven with mitral-aortic intervalvular fibrosa perforations, one of two with anterior mitral leaflet aneurysms, and one of seven anterior mitral leaflet perforations. Eccentric mitral regurgitation-type systolic jets were noted in eight additional patients by transthoracic color flow imaging, and this finding suggested the possibility of these unusual subaortic complications. If these patients are included, then transthoracic echocardiography suggested the presence of these subaortic complications in 13 of 24 patients (54%). CONCLUSIONS. The results indicate that 1) involvement of the subaortic structures in patients with aortic valve endocarditis may be more common than previously recognized, 2) patients with aortic valve endocarditis and eccentric jets of mitral regurgitation on transthoracic echocardiography should undergo further evaluation by transesophageal echocardiography to exclude these unusual complications, 3) precise recognition of these complications is of value in the optimal medical and surgical management of these patients, and 4) these complications may be responsible for unexplained congestive heart failure and hemodynamic deterioration in some patients with aortic valve endocarditis.

J Am Coll Cardiol. 1995 Jan;25(1):137-45.
Pseudoaneurysms of the mitral-aortic intervalvular fibrosa: dynamic characterization using transesophageal echocardiographic and Doppler techniques.
Afridi I, Apostolidou MA, Saad RM, Zoghbi WA.
Department of Medicine, Baylor College of Medicine, Methodist Hospital, Houston, Texas 77030.

OBJECTIVES. The aim of this study was to provide a detailed description of echocardiographic and Doppler features of pseudoaneurysms involving the mitral-aortic intervalvular fibrosa and to compare echocardiographic and aortographic findings. BACKGROUND. Infection of the aortic valve may spread to the aortic annulus, resulting in ring abscesses or pseudoaneurysms, or both, of the intervalvular fibrosa, which can alter patient management and prognosis. METHODS. The echocardiographic and Doppler findings of 20 patients with pseudoaneurysms or ring abscesses, or both, were reviewed and compared with surgical and aortographic results. RESULTS. A total of 23 lesions were identified, of which 16 were intervalvular pseudoaneurysms, and 7 were ring abscesses. Transthoracic echocardiography detected 43% of the lesions, whereas transesophageal echocardiography identified 90% (p < 0.01). The most distinct feature of the pseudoaneurysms was marked pulsatility, with systolic expansion and diastolic collapse (mean systolic area [+/- SD] 4.1 +/- 3.4 cm2 vs. diastolic mean area 1.8 +/- 2.2 cm2, p < 0.05). Using color Doppler, two types were identified: unruptured pseudoaneurysms (n = 9), which communicated only with the left ventricular outflow tract and had a distinct flow pattern, and ruptured pseudoaneurysms (n = 7), which, in addition, communicated with the left atrium or aorta. Compared with pseudoaneurysms, ring abscesses were smaller and nonpulsatile and showed either no flow or continuous systolic and diastolic flow, the site of paravalvular aortic insufficiency. In 10 patients who underwent aortography, three lesions were identified, and findings were concordant with echocardiography. However, in seven patients aortographic findings were normal, whereas echocardiography identified intervalvular pseudoaneurysms, all of which were documented at operation. CONCLUSIONS. Intervalvular pseudoaneurysms are more frequently detected by transesophageal echocardiography than by aortography or transthoracic examination and exhibit distinct dynamic features and Doppler patterns that can further help characterize cavitary lesions in the aortic root and guide appropriate surgical intervention.

J Am Soc Echocardiogr. 1988 Sep-Oct;1(5):354-8.
Traumatic left ventricular false aneurysm with significant regurgitation from left ventricular outflow tract to left atrium: delineation by two-dimensional and color flow Doppler echocardiography.
Taliercio CP, Oh JK, Summerer MH, Butler CF, Danielson GK.
Division of Cardiovascular Diseases and Internal Medicine, Mayo Clinic, Rochester, MN 559051.

A 22-year-old man was asymptomatic 23 months after an automobile accident but had clinical evidence of progressive mitral insufficiency. Two-dimensional and color flow Doppler echocardiography demonstrated a false aneurysm adjacent to the left ventricular outflow tract and significant regurgitation of blood through a traumatic channel from the left ventricular outflow tract to the left atrium. The patient underwent successful surgical closure of the false aneurysm and repair of the traumatic left atrial regurgitation.

J Am Soc Echocardiogr. 2002 Jul;15(7):743-5.
False aneurysm of the mitral-aortic intervalvular fibrosa after uncomplicated aortic valve replacement.
Rodrigues Borges AG, Suresh K, Mirza H, Katz JP, Simandl SL, Bilfinger T, Cohn PF.
Echocardiography Laboratory, Division of Cardiology, State University of New York, Stony Brook, New York 11794, USA.

False aneurysms of the mitral-aortic intervalvular fibrosa are rare and usually complicate aortic valve endocarditis. We report a case of a false aneurysm of the mitral-aortic intervalvular fibrosa after recent bioprosthetic aortic valve replacement in the absence of endocarditis.

J Am Soc Echocardiogr. 2003 Aug;16(8):894-6.
Stroke in patient with an intervalvular fibrosa pseudoaneurysm and aortic pseudoaneurysm.
Koch R, Kapoor A, Spencer KT.
Department of Cardiology, University of Chicago, Chicago, Illinois 60637, USA.

We describe a case of an intervalvular fibrosa pseudoaneurysm associated with a cerebrovascular accident. This case in unusual as the likely source of embolic stroke was thrombus from within the pseudoaneurysm. Transesophageal echocardiography also demonstrated a communication between the intervalvular fibrosa and the proximal aorta.

J Am Soc Echocardiogr. 1994 Jan-Feb;7(1):72-8.
Transesophageal echocardiographic recognition of an unusual complication of aortic valve endocarditis.
Harpaz D, Shah P, Hicks G, Meltzer R.
Cardiology Unit, University of Rochester, NY.

Aortic valve endocarditis can cause complications due to involvement of the subaortic structures. These complications include satellite vegetations on the aortic regurgitant jet lesion sites, involvement of the anterior or posterior mitral valve leaflets in the form of aneurysms, perforation, and involvement of the mitral-aortic intervalvular fibrosa, namely abscess, aneurysm, and perforation into the left atrium or the pericardial sac. These complications can be identified accurately by echocardiography. We report an unusual case which demonstrates (1) coexistence of both mitral-aortic intervalvular fibrosa and mitral valve aneurysms, and (2) echocardiographic follow-up of a mitral valve aneurysm to perforation. These complications were recognized by transesophageal echocardiography and verified at surgery.

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