Three‐Dimensional Echocardiographic Delineation of an Acquired Aorto‐Left Atrial Fistula Complicating Native Aortic Valve Endocarditis – “Advantage of Three Dimensions”

Aorto‐atrial fistulas are rare, but important complications resulting from aortic valve infective endocarditis, aortic valve surgery, or aortic dissection. We hereby report a case of a 20‐year male, referred to us with infective endocarditis of the native aortic valve with severe aortic regurgitation and symptoms of heart failure. Detailed evaluation with two‐dimensional and three‐dimensional transthoracic echocardiography revealed aorto‐left atrial fistula secondary to the involvement of the mitral–aortic intervalvular fibrosa (MAIVF) region. The patient underwent successful removal of the vegetations, closure of the defect along with aortic valve replacement, and mitral valve repair.     

Pseudoaneurysm of mitro-aortic intervalvular fibrosa during the course of mitral valve endocarditis with aorto-left ventricle outflow tract fistula

The mitro-aortic intervalvular fibrosa (MAIVF) connects the anterior mitral leaflet to the posterior portion of the aortic annulus.The pseudoaneurysm of MAIVF is one of the uncommon but catastrophic complications of native or prosthetic aortic valve endocarditis or chest trauma.We report a case of infective endocarditis of mitral valve complicated by development of pseudoaneurysm of MAIVF, and fistulous formation causing massive shunt flow from the ascending aorta above the non-coronary cusp to the left ventricle outflow tract.     

Transesophageal echocardiographic recognition of subaortic complications in aortic valve endocarditis. Clinical and surgical implications.

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.     

3D Echocardiographic Delineation of Mitral‐Aortic Intervalular Fibrosa Pseudoaneurysm Caused by Bicuspid Aortic Valve Endocarditis

Pseudoaneurysm of the mitral‐aortic intervalvular fibrosa is a rare complication of infective endocarditis of the aortic valve eventually resulting in coronary artery compression, stroke or rupture into the left atrium, aorta or pericardial space. A prompt diagnosis by either transthoracic or transesophageal echocardiography is mandatory to address the patient to cardiac surgery. We report the clinical case of a 25‐year‐old white man who was admitted to the emergency department for dyspnoea and fever. Echocardiographic examination showed a bicuspid aortic valve with a huge sessile vegetation and a pseudaneurysm of the mitral‐aortic intervalvular fibrosa. In addition to conventional two‐dimensional examination, three‐dimensional echocardiography provided additional information of this complication, precisely delineating the lesions and addressing the cardiac surgeon in choosing the most appropriate operating strategy. Patient underwent then aortic root replacement and the pseudoaneurysm was closed by means of a bovine pericardial patch. (Echocardiography 2011;28:E1‐E4)     

Pseudoaneurysm of the mitral-aortic intervalvular fibrosa following infective endocarditis in a patient with acute heart failure: a case report

A 22-year-old male presented with infective endocarditis and aortic regurgitation with congenital bicuspid aortic valve. Echocardiography revealed vegetation on the aortic valve and a pseudoaneurysm in the region of the mitral-aortic intervalvular fibrosa (MAIVF) with severe aortic and mitral regurgitation. His clinical condition, acute heart failure due to severe aortic and mitral regurgitation, became worse. Since the MAIVF complication indicates advanced disruption of tissue at the MAIVF, urgent cardiac surgery was indicated because of the evidence of pseudoaneurysm. He received successful aortic valve replacement and restoration of normal mitral-aortic continuity. Pseudoaneurysm of the MAIVF is a relatively rare complication of infective endocarditis, but should be considered in patients who are suspected to have vegetation because echocardiography can easily establish the correct diagnosis.     

Left ventricular outflow tract pseudoaneurysm after aortic valve replacement: case report

A 68-year-old woman was admitted for angina pectoris and general fatigue without symptoms or signs of infective endocarditis. The patient had undergone re-replacement of an aortic prosthetic valve three months previously. Transesophageal echocardiography revealed an echo-free cavity in the mitral-aortic intervalvular fibrosa region just below the aortic annulus, communication of the echo-free cavity with the left ventricular outflow tract, and turbulent flow into the cavity. Left ventriculography revealed a cavity that arose just below the aortic prosthetic valve, and which expanded in systole and collapsed in diastole. Coronary angiography showed significant stenosis of the proximal right coronary artery, but neither stenoses nor compression were found in the left coronary artery. Patch closure of the pseudoaneurysm and aortic root replacement using a Freestyle valve with reconstruction of the coronary arteries were successfully performed. Surgical trauma to the intervalvular fibrosa during removal of the original prosthetic valve may have caused pseudoaneurysm formation in this patient.     

Reconstruction of the Fibrous Trigone

A 48-year-old man with a history of infective endocarditis and severe aortic regurgitation had undergone prosthetic aortic valve replacement at another institution. Two months later, the patient developed prosthetic valve endocarditis with an aortic root abscess and an aorto–left atrial periprosthetic valvular fistula through the detached posterior annulus of the mitral valve. We repaired the fistula by constructing a fibrous trigone made of bovine pericardium. We also replaced the prosthetic aortic valve with another prosthetic valve, while protecting the native mitral valve.Key words: Aortic valve replacement, endocarditis/complications/surgery, fistula/etiology/surgery, heart valve prosthesis/adverse effects, mitral valve repair, prosthesis-related infections, reoperationThe incidence of prosthetic valve endocarditis (PVE) within 12 months after heart valve replacement is between 1% and 3.1%.^1,2 In the largest PVE case series to date, 20.1% of the cases of infective endocarditis were due to PVE³—a severe and life-threatening infection, particularly when accompanied by a paraprosthetic abscess and progression of fistulous communication.Aorto–left atrial fistula, a rare complication of PVE, is surgically challenging. We report the successful surgical repair of an aorto–left atrial periprosthetic valvular fistula in concordance with re-replacement of the aortic valve, while protecting the native mitral valve.     

Transapical Closure of a Pseudoaneurysm of the Mitral-Aortic Intervalvular Fibrosa

Pseudoaneurysm of the mitral-aortic intervalvular fibrosa is a rare but serious sequela of endocarditis or valve replacement surgery. Because open-heart surgery is a high-risk treatment option, alternative methods are sought. We present the case of a 77-year-old man with a noninfected mechanical mitral valve whose pseudoaneurysm was repaired by introducing an occluder device into the defect by a transapical approach. Upon follow-up imaging, the defect was successfully closed. We conclude that percutaneous closure of pseudoaneurysm of the mitral-aortic intervalvular fibrosa is a viable alternative to surgery and that a transapical approach is an appropriate method of access.     

Pseudoaneurysm of the Mitral-Aortic Intervalvular Fibrosa: A Long-Term Complication of Infective Endocarditis

Pseudoaneurysms of the left ventricle are rare and may occur as a result of transmural myocardial infarction, chest trauma, cardiac surgery, or endocarditis. Although postinfarction pseudoaneurysms commonly arise in the mid and apical segments of the left ventricle, those resulting from endocarditis arise at the base of the heart. Here we report the case of a patient who developed a large pseudoaneurysm as a complication of aortic valve endocarditis. The pseudoaneurysm had two uncommon features; it originated from the intervalvular fibrous body connecting the mitral to the aortic valve, and it eroded through the chest wall, resulting in blood drainage through the skin.     

Pseudoaneurysm Formation in Infective Endocarditis

Left ventricular pseudoaneurysms that develop in the setting of infective endocarditis are believed to result from remodeling of extravalvular abscesses. The high pressure generated by the left ventricle is thought to dissect into the abscess causing it to form a characteristic sac‐like protuberance readily recognized echocardiographically. Left ventricular pseudoaneurysms most often arise from abscesses in the mitral‐aortic intervalvular fibrosa and protrude external to the aorta. Less often, as described herein, they arise from abscesses external the posterior mitral annulus and project into the posterior interventricular groove. Perforation may result in camo‐cameral or aorto‐cameral fistula formation, as well as fistulous communication with the pericardial space.     

Multimodality imaging evaluation of a mitro‐aortic fibrosa pseudoaneurysm fistulizing into both atria

To our knowledge, we describe the first case of a pseudoaneurysm of the mitro‐aortic intervalvular fibrosa fistulizing into both atria, following an aortic bacterial endocarditis and valve replacement.     

Mitral‐aortic intervalvular fibrosa pseudoaneurysm causing compression of superior vena cava and right atrium

The mitral‐aortic intervalvular fibrosa (MAIVF) is a fibrous, avascular region between the anterior leaflet of the mitral valve and noncoronary cusp of the aortic valve. This makes MAIVF vulnerable to injury and infection; thus pseudoaneurysm may develop. The pseudoaneurysm can cause compression to coronary arteries which causes angina or pulmonary artery resulting in pulmonary hypertension. We presented the pseudoaneurysm of MAIVF causing compression of superior vena cava and right atrium which was visualized by two‐ and three‐dimensional transesophageal echocardiography and cardiac computed tomography.     

Images in cardiovascular medicine: prosthetic aortic valve and conduit dehiscence with large periconduit cavity, ascending aortic aneurysm and severe mitral regurgitation

Prosthetic aortic valve and conduit dehiscence with periconduitcavity and ascending aortic aneurysm is an uncommon complicationof aortic root surgery. It is usually recognizable at echocardiographydue to an abnormal position of the prosthetic valve and conduitin relation to the native aortic annulus in conjunction withan abnormal echolucent periconduit space that fills with colorflow. Mitral regurgitation is an unusual complication of thiscondition. We present a patient with severe mitral regurgitation secondaryto prosthetic aortic valve and conduit dehiscence with a largepericonduit cavity and aneurysm of the intervalvular fibrosa.The mechanism of mitral regurgitation is secondary to functionalinvolvement of the anterior mitral valve leaflet and intervalvularfibrosa with anterior mitral leaflet restriction in conjunctionwith mild left ventricular remodeling. Significant mitral regurgitationpersisted post resection of the periconduit cavity and aorticvalve replacement, requiring mitral valve replacement. This case study reports a new mechanism of mitral regurgitationin the setting of prosthetic aortic valve and conduit dehiscence.     

Acquired AortoVentricular Tunnel: A Rare Complication of Infective Endocarditis

A 26-year-old man presented to emergency department with fever associated with night sweating and weight loss since 2 months prior to admission. He was an intravenous heroin user admitted for infective endocarditis of aortic valve 1 year ago. Transthoracic echocardiography followed by the transesophageal study showed bileaflet aortic prosthesis with normal transvalvular gradient and severe paravalvular aortic insufficiency. A pseudoaneurysm of intervalvular fibrosa connecting left ventricular outflow tract (LVOT) to noncoronary sinus of valsalva was detected.     

The Preoperative Evaluation of Infective Endocarditis via 3-Dimensional Transesophageal Echocardiography

Transesophageal echocardiography continues to have a central role in the diagnosis of infective endocarditis and its sequelae. Recent technological advances offer the option of 3-dimensional imaging in the evaluation of patients with infective endocarditis. We present an illustrative case and review the literature regarding the potential advantages and limitations of 3-dimensional transesophageal echocardiography in the diagnosis of complicated infective endocarditis.A 51-year-old man, an intravenous drug user who had undergone bioprosthetic aortic valve replacement 5 months earlier, presented with prosthetic valve endocarditis. Preoperative transesophageal echocardiography with 3D rendition revealed a large abscess involving the mitral aortic intervalvular fibrosa, together with a mycotic aneurysm that had ruptured into the left atrium, resulting in a left ventricle-to-left atrium fistula. Three-dimensional transesophageal echocardiography enabled superior preoperative anatomic delineation and surgical planning. We conclude that 3-dimensional transesophageal echocardiography can be a useful adjunct to traditional 2-dimensional transesophageal echocardiography as a tool in the diagnosis of infective endocarditis.     

A rare complication of mechanical aortic valve replacement: Separation in the region of the mitral‐aortic intervalvular fibrosa

A 28‐year‐old man was admitted to our emergency service with a shortness of breath and palpitation. On admission, his blood pressure was high and he was in hypertensive pulmonary edema. His physical examination showed rales in both lungs and pansystolic murmur at mitral focus. His medical history included aortic valve replacement (AVR) because of native aortic valve infective endocarditis. Transthoracic echocardiography (TTE) showed normal functional aortic valve. Color flow imaging demonstrated severe mitral regurgitation with posterior eccentric jet. To examine in detail, transesophageal echocardiography (TEE) and three‐dimensional (3D) echocardiography were performed. TEE disclosed a separation in the subaortic curtain leading to severe mitral regurgitation from the left ventricle to the left atrium. In addition to severe mitral regurgitation with posterior eccentric jet, 26‐mm‐long pouch was seen in mitral‐aortic intervalvular fibrosa (MAIVF) at 120° TEE view. This pouch was separated from the mitral anterior leaflet junction releasing the mitral anterior leaflet and causing prolapse and chorda rupture in the A2 scallop of the mitral anterior leaflet. The MAIVF connects the anterior mitral leaflet to the posterior portion of the aortic annulus. The separation of the MAIVF represents a complication of the aortic valve replacement.     

Native Aortic Valve Endocarditis Complicated by Pseudoaneurysm of Mitral‐Aortic Intervalvular Fibrosa

Pseudoaneurysm of mitral‐aortic intervalvular fibrosa (PA‐MAIVF) is a rare complication of native aortic valve endocarditis. This region is a relatively avascular area and prone to infection during endocarditis and subsequent aneurysm formation. The rupture into the pericardial cavity and left atrium or aorta, systemic embolism, myocardial infarction secondary to left coronary compression, and sudden death are the reported complications. Herein, we present a 9‐year‐old boy who was diagnosed with bicuspid aortic valve endocarditis complicated by PA‐MAIVF, cerebral embolism, and hemorrhage. PA‐MAIVF was visualized by both two‐ and three‐dimensional transthoracic echocardiography and ruptured into pericardial space causing a fatal outcome.     

Changing conduction abnormalities in a dialysis patient with fever

A patient on hemodialysis with severe aortic valve disease and presumed arteriovenous fistula infection was found to have new-onset atrial fibrillation and alternating left and right bundle branch block patterns on serial electrocardiograms. These findings prompted transesophageal echocardiography, which revealed a large abscess involving the intervalvular fibrosa and the posterior cusp of the bicuspid aortic valve. Hence, basic bedside diagnostic skills remain important in the era of sophisticated imaging techniques and laboratory analyses.     

Diagnosis of Fistulas of the Mitral-Aortic Intervalvular Fibrosa

A 57-year-old white male status post St. Jude aortic prosthesis, who 10 years later presented with congestive heart failure was found to have a fistula between the left ventricular outflow tract and left atrium at the mitral-aortic intervalvular fibrosa with no evidence of endocarditis or trauma.     

A pseudoaneurysm of the mitral-aortic intervalvular fibrosis after aortic valve replacement]

A 58-year-old male underwent a transesophageal echocardiogram for suspected aortic valve infective endocarditis, four years after surgery. The examination, performed with a multiplane probe, showed a pulsatile (systolic expansion) echo-free cavity in the intervalvular mitral-aortic region, communicating with the left ventricle outflow tract, with no signs of rupture to the left atrium or the aorta. These findings meet the criteria for the diagnosis of pseudoaneurysm of the mitral-aortic intervalvular fibrosa.