Methodist Journal

FEATURED GUEST EDITOR

ISSUE INTRO

The Scourge of Cardiogenic Shock

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RECOGNITIONS

Arvind Bhimaraj, MD, MPH, Guides Issue on Cardiogenic Shock

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REVIEW ARTICLES See More

Pathophysiology and Advanced Hemodynamic Assessment of Cardiogenic Shock

Cardiogenic Shock in the Setting of Acute Myocardial Infarction

Cardiogenic Shock in Patients with Advanced Chronic Heart Failure

Acute Mechanical Circulatory Support for Cardiogenic Shock

Management of Cardiogenic Shock in a Cardiac Intensive Care Unit

Physiological Concepts of Cardiogenic Shock Using Pressure-Volume Loop Simulations: A Case-Based Review

Systems of Care in Cardiogenic Shock

Heart Failure in Relation to Anthracyclines and Other Chemotherapies

CASE REPORTS See More

Repair of Extent III Thoracoabdominal Aneurysm in the Presence of Aortoiliac Occlusion

A Rare Case of Pancreatitis-Induced Thrombosis of the Aorta and Superior Mesenteric Artery

Anomalous Origin of the Right Coronary Artery from the Left Main Coronary Artery in the Setting of Critical Bicuspid Aortic Valve Stenosis

Simultaneous Transfemoral Mitral and Tricuspid Valve in Ring Implantation: First Case Report with Edwards Sapien 3 Valve

MUSEUM OF HMH MULTIMODALITY IMAGING CENTER See More

Do Not Pass Flow: Microvascular Obstruction on Cardiac Magnetic Resonance After Reinfarction Following Primary Percutaneous Coronary Intervention

CLINICAL PERSPECTIVES See More

EXCERPTA

Cardio-Oncology, Then and Now: An Interview with Barry Trachtenberg

POINTS TO REMEMBER

Onconephrology: An Evolving Field

POINTS TO REMEMBER

Herbal Nephropathy

EXCERPTA

Rolling the Dice on Red Yeast Rice

EDITORIALS

Letter to the Editor in Response to “Cardiac Autonomic Neuropathy in Diabetes Mellitus”

Vol 14, Issue 2 (2018)

Article Full Text

MUSEUM OF HMH MULTIMODALITY IMAGING CENTER

A Case of Infected Mitral-Aortic Intervalvular Fibrosa Pseudoaneurysm

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Article Citation:

Malahfji M, Chamsi-Pasha M, Chang SM. A Case of Infected Mitral-Aortic Intervalvular Fibrosa Pseudoaneurysm. Methodist DeBakey Cardiovasc J. 2018;14(2):151-152.

doi: 10.14797/mdcj-14-2-151

Keywords
intervalvular fibrosa pseudoaneurysm , prosthetic valve infection

An 81-year-old woman presented with fever and shortness of breath. She had an aortic valve replacement in 2012 (a 19-mm St. Jude Trifecta bioprosthetic valve) as well as coronary artery bypass grafting. Blood cultures were positive for vancomycin-intermediate Staphylococcus aureus. Transthoracic echocardiography showed degeneration of the aortic valve prosthesis with severe aortic insufficiency and a tricuspid valve vegetation.

Transesophageal echocardiography demonstrated pseudoaneurysm formation in the mitral-aortic intervalvular fibrosa (MAIVF) (Figures 1, 3). Color Doppler showed systolic and diastolic flow into the pseudoaneurysm (Figure 2). Cardiac computed tomography showed that the ruptured abscess cavity extended from the aortic root to the proximal ascending aorta (Figure 4, red arrow).

The patient underwent debridement of the aortic annulus as well as aortic root and ascending aorta replacement using a CryoLife allograft (CryoLife, Inc.). The tricuspid valve vegetation was removed, and intravenous antibiotic therapy was continued for 8 weeks with daptomycin and ceftaroline followed by lifelong doxycycline therapy. She was discharged to rehabilitation 2 weeks later.

The MAIVF is a fibrous structure located at the junction of the anterior mitral leaflet and the noncoronary cusp of the aortic valve. It is relatively avascular, which makes it prone to infection and injury resulting in pseudoaneurysm formation. When making the diagnosis, it is important to visualize the echo-free space with systolic expansion and diastolic collapse of the pseudoaneurysm.1 Patients with ring abscesses in the MAIVF region, prosthetic aortic valves, or histories of endocarditis are at higher risk for developing pseudoaneurysm of the MAIVF. Transesophageal echocardiography is critical to make the diagnosis.2

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References
  1. Afridi I, Apostolidou MA, Saad RM, Zoghbi WA. Pseudoaneurysms of the mitral-aortic intervalvular fibrosa: dynamic characterization using transesophageal echocardiographic and Doppler techniques. J Am Coll Cardiol 1995 Jan;25(1):137-45.
  2. Sudhakar S, Sewani A, Agrawal M, Uretsky BF. Pseudoaneurysm of the mitral-aortic intervalvular fibrosa (MAIVF): A comprehensive review. J Am Soc Echocardiogr. 2010 Oct;23(10):1009-18.

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