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The copyright of this thesis vests in the author. No quotation from it or information derived from it is to be published without full acknowledgement of the source. The thesis is to be used for private study or non-commercial research purposes only.

Published by the University of Cape Town (UCT) in terms of the non-exclusive license granted to UCT by the author.

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Section 2 183

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6, Section 2 183

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25 present only if the aneurysm is not of recent origin [14,1 *]. The lung

fields may commonly demonstrate upper lobe diversion of pulmonary

blood flow consistent with pulmonary venous congestion.

(Figure 3) Postero-anterior (A) and lateral (8) chest radiograph of a 64

year old woman, showing large multiloculated calcified submitral

aneurysm. (Arrows)

With permission: John W Barlow

Perspectives on the Mitral valve

Chapter 6, Section 2 Page 183

2. Electrocardiographical Features

The ECG is normal in a minority of cases, and Chessler found only one

completely normal ECG in 15 patients with submitral aneurysms [2].

Electrocardiographical evidence of left ventricular hypertrophy, out of

proportion to the severity of the mitral regurgitation, may suggest the

possibility of an additional hemodynamic load on the left ventricle [1 *].

Low voltages, nonspecific ST -segment and T-wave changes and signs of

myocardial ischaemia or infarction may be encountered.

Electrocardiographical evidence of ischaemia is often due to distortion or

obstruction of the left circumflex coronary artery along its course in the

atrioventricular groove [4,9,13]. Patients presenting with ventricular

tachycardia have also been encountered [4]. Atrial fibrillation is also

common due to the left atrial enlargement [14J.

Conduction disturbances such as first-degree heart block are not

uncommon and may also be related to myocardial ischaemia produced by

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A

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(Figure 4 A, B) (A) Angiogram in the right anterior oblique position. (B)

Angiogram in the Left lateral position, both demonstrating a LVSMA.

(AO) Aorta, (LV) Left ventricle, (AN) Aneurysm, (LA) Left atrium, (T)

Thoracic aorta. The arrows in (B) demonstrates the calcified rim of the

LVSMA

With permission: John W Barlow

Perspectives on the Mitral valve

Chapter 6, Section 2 Page 183

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4. Echocard iographic Features

2-D echocardiography demonstrates a submitral aneurysm as an echo­

free space arising below the posterior mitral leaflet extending postero­

medially and superiorly to compress the left atrial cavity. Communication

with the left ventricular cavity can then be seen in the region of the

atrioventricular groove. The mitral valve apparatus is very well visualized

and mitral incompetence can readily be demonstrated. Mitral

incompetence is usually due to lack of leaflet co-aptation and distortion of

the mitral valve. Because of cardiac displacement and variable position of

the aneurysms, unconventional views are sometimes necessary to

demonstrate them. Left ventricular (LV) contrast echocardiography can

also be used [23]. A pigtail catheter is placed in the LV and the patients

blood is used as the contrast agent to determine mitral regurgitation and

to locate the neck of an aneurysm. A flail posterior leaflet provides

important ancillary evidence of the existence of a submitral aneurysm,

provided that other causes such as degenerative myxomatous disease,

trauma, infective endocarditis, and acute rheumatic carditis have been

excluded.

Fig 5 A

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A

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c Fig 5 B

(Figure 5 A,B) 2-D echocardiography pictures demonstrating two different

patients with LVSMA. The LVSMA is seen as an echo-free space arising

below the posterior mitral leaflet extending postero-medially and

superiorly to compress the left atrial cavity. (Ao) Aorta, (LA) Left atrium,

(MV) Mitral valve, (An) Aneurysm, (LV) Left ventricle, (N) Neck of

aneurysm, (AL) Anterior leaflet on mitral valve, (PL) Posterior leaflet of

mitral valve

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30 5. Computed Tomography (CT)

The use of CT and contrast CT in defining the position, size, presence and

extent of thrombus and calcification has represented a major advance in

the diagnosis and assessment of submitral aneurysms. Barlow reports

that CT was positive in all seven patients in whom it was performed, and

the information obtained equaled or surpassed that derived from

angiography [1 *]. CT provides an excellent non-invasive method of

investigation in suspected cases of submitral aneurysm.

A

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B

(Figure 6) A) Consecutive contrasted Computed tomography (CT) scan in

a 31 year old male demonstrating the (A) aneurysm and its

communication, via a wide neck (N) with the left ventricle (LV) Extensive

thrombus formation is seen in the aneurysm.

(Figure 6) B) Single frame of CT scan sequence clearly demonstrating the

LVSMA (AN) in relation to the aorta (AG), left ventricle (LV) and the left

atrium (LA).

With permission: John W Barlow

Perspectives on the Mitral valve

Chapter 6, Section 2 Page 183

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Annular Subvalvar left ventricular aneurysms

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(Figure 8 A) : Left Ventriculograms in the right anterior oblique plane.

LVSMA expanded and involving the whole mitral annulus as found in two

of the patients in Group III. Contrast medium has been injected into the

left ventricle (LV) via the aortic root (A). The contrast media is seen filling

the LV and the left atrium (LA) indicating severe mitral incompetence. The

LVSMA (AN) is outlined with the dashed line.

Fig A: With Permission: H.J. Du Toit et al.

Interactive Cardiovascular and Thoracic Surgery 2 (2003) 547-

551

Aneurysms tend to be large as shown in the intra-operative photograph

because they track in a circular direction. Enlargement is laterally,

anteriorly and superiorly by herniation through the attachment of the left

ventricular muscle and the fibrous valve ring. They may be loculated and

in all instances contain clot, fresh and laminated, as well as cellular debris.

Calcification of the laminated clot may develop

(Figure 9)

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(Figure 9): Intra-operative photograph of a LVSMA, shown here as the

whitish bulging structure to the left of the image. The aortic cannula

(cranial) is seen in the centre bottom of the photograph and the

diaphragm at the top (caudal) Arrows indicating LVSMA

The left atrium may be compressed and the circumflex artery may be

greatly stretched and narrowed along its course in the atrio-ventricular

groove by the aneurysm. This may produce symptoms of angina pectoris

and may lead to myocardial infarction due to coronary artery occlusion or

thrombosis.

(Figure 10,11)

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(Figure 10) Diagrammatic representation of stretching and compression

38

of the circumflex coronary artery by the enlarging aneurysm. A) Reflection

of the pericardium demonstrating the relationship of the cardiac

structures. B) Saggital view of the LVSMA. C) Compression of the

circumflex coronary artery by the aneurysm

From: Clerkin lP, Bunje H

Rare cardiac aneurysm in a young adult

Thorax 1955;10:42-45

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(Figure 11) Angiogram of the Left coronary system in the right anterior

oblique plane. Stretching and partial occlusion of the circumflex artery is

demonstrated (lower right of picture)

From : Clerkin JP, Bunje H

Rare cardiac aneurysm in a young adult

Thorax 1955;10:42-45

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(Figure 13) Intra-operative photograph of extra-cardiac approach. The

forceps and eyelid retractor are in the aneurysm cavity_ A patch of

autologous pericardium is being sewn into place

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