J Cardiol 2007 Jun; 49（6）: 353 – 356

Pseudoaneurysm of the MitralAortic Intervalvular Fibrosa
Following Infective Endocarditis ina Patient With Acute Heart Failure :A Case Report
YosukeShin-ichiro

TAKAMIYA, MD
MIURA, MD, FJCC

Hideto

SAKO, MD

Kazuyuki

SHIRAI, MD

Noritsugu

MORISHIGE, MD＊Tadashi

TASHIRO, MD, FJCC＊Keijiro

SAKU, MD, FJCC

Abstract ─────────────────────────────────────────────────────────────────────────────────────────────────────────────────────────────────────────────────────────────────────
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 theregion 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 theMAIVF complication indicates advanced disruption of tissue at the MAIVF, urgent cardiac surgery wasindicated because of the evidence of pseudoaneurysm. He received successful aortic valve replacement andrestoration 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.
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Key Words■ Aneurysms（mitral-aortic intervalvular fibrosa）■ Endocarditis（infective）■ Heart failure（acute）

INTRODUCTION
Pseudoaneurysm of the mitral-aortic intervalvular fibrosa（MAIVF）
is a rare complication of infec1, 2）
The accurate detection oftive endocarditis.
pseudoaneurysm of the MAIVF is crucial in overallpatient management and in surgical guidance
because the pseudoaneurysm may not be readily
identified during surgery. In addition, cardiac surgical intervention is increasingly important in thetreatment of patients with infective endocarditis.3, 4）
Mortality is unacceptably high when patients withcomplications are treated with only antibiotics, butmortality is reduced when antibiotics are combinedwith surgical intervention.5, 6）Accordingly, complications have become indications for cardiac
surgery.
We report a case of infective endocarditis withcongenital bicuspid aortic valve complicated by thedevelopment of a pseudoaneurysm of MAIVF withacute heart failure. The diagnosis was confirmed atsurgery and appropriate treatment was instituted.
The postoperative course was uncomplicated.

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福岡大学医学部 心臓血管内科，＊心臓血管外科 : 〒 814−0180 福岡市城南区七隈 7−45−1
Departments of Cardiology and ＊ Cardiovascular Surgery, Fukuoka University School of Medicine, Fukuoka
Address for correspondence : MIURA S, MD, FJCC, Department of Cardiology, Fukuoka University School of Medicine, Nanakuma
7−45−1, Jonan-ku, Fukuoka 814−0180 ; E-mail : miuras@cis.fukuoka-u.ac.jp
Manuscript received January 31, 2007 ; revised March 21, 2007 ; accepted March 22, 2007353

354

Takamiya, Miura, Sako et alFig. 1 Chest radiographs at 4 months before admission（a）
and at admission（b）

CASE REPORT
A 22-year-old male was admitted with high fever
and abnormal echocardiography findings suggesting infective endocarditis. The diagnosis was aortic
regurgitation with congenital bicuspid aortic valve
4 months earlier and surgery was scheduled for aortic valve replacement. About 2 weeks prior toadmission, his physician had treated him with
antibiotics for cellulitis. He was subsequently
admitted for intravenous antibiotic treatment
because of severe infection.
Physical examination revealed his blood pressure
was 152/52 mmHg, and his pulse was 89/min andregular. Auscultation of the heart revealed grade 4/6
to and fro murmur and grade 3/6 diastolic murmur.
Lung examination revealed no abnormalities. The
extremities did not show any peripheral edema.
Blood chemistry values were within normal limits
except for C-reactive protein and brain natriuretic
peptide, which were 4.5 and 912 pg/ml, respectively. All blood cultures remained negative. Chest
radiography showed cardiomegaly（cardiothoracicratio 62%）and severe pulmonary vascular congestion, although the cardiac silhouette was normal（cardiothoracic ratio 50%）and no evidence of congestion at 4 months before admission（Fig. 1）.
Echocardiography was important in the diagnosisof this case（Fig. 2）. The two-dimensional view
revealed vegetation on the aortic value and a 10 ×
10 mm pseudoaneurysm in the region of theMAIVF. The size did not change in systole andFig. 2 Two-dimensional echocardiogram
Arrows indicate aortic valve with vegetation（No. 1）and
pseudoaneurysm in the region of the mitral-aortic intervalvular fibrosa（No. 2）, respectively.

diastole. Color Doppler echocardiography demonstrated slight forward flow from the left ventricle
into the pseudoaneurysm. Color flow imaging
showed aortic regurgitation（degree Ⅳ）and mitralregurgitation（degree Ⅲ−Ⅳ）. Tricuspid regurgitation was also observed and the pressure gradientwas 33 mmHg. In addition, the left ventricularinternal diameter was extremely enlarged in diastole（82 mm）and systole（60 mm）.
The clinical course of the patient is shown in Fig.
3. Although he was given gentamicin and cefroxadine after admission, his clinical condition, acuteheart failure due to severe aortic and mitral regurgiJ Cardiol 2007 Jun; 49（6）: 353 – 356

Mitral-Aortic Intervalvular Fibrosa

355

Fig. 3 Clinical course of the patient
Solid, gray and dotted lines indicate body temperature, cardiothoracic ratio and C-reactive protein, respectively.
CRP ＝ C-reactive protein ; BT ＝ body temperature ; CTR ＝ cardiothoracic ratio.

tation, became worse. He underwent an urgent
operation and received successful aortic valve
replacement and excision of the pseudoaneurysm（Fig. 4）
. Perforation was implicated in the entry ofpseudoaneurysm. He also underwent reconstructionof the intervalvular fibrous body and restoration of
normal mitral-aortic continuity.
DISCUSSION
Echocardiography is important in the visualization of valvular vegetations, abscesses and othercomplications in patients with infective endocarditis. One such complication is the development ofMAIVF. Aneurysms are prone to rupture, embolize
or even cause further destruction of the aortic or
mitral valve apparatus.7, 8）Therefore, it is importantto recognize the complication early, and to instituteappropriate surgical treatment in a timely fashion todecrease morbidity and mortality. This case report
describes a patient with a protracted course of
infective endocarditis who presented with MAIVF
complication.
MAIVF is the junction between the left half ofthe non-coronary cusp and the adjacent third of theleft coronary cusp of the aortic valve and the anterior mitral leaflet. Among 55 consecutive patientswith aortic valve endocarditis, 24 showed involvement of the subaortic structures.1）Thus, MAIVF is
an important complication of infective endocarditis.
J Cardiol 2007 Jun; 49（6）: 353 – 356

Fig. 4 Mitral valve and pseudoaneurysm of themitral-aortic intervalvular fibrosa
MAIVF ＝ mitral-aortic intervalvular fibrosa.

The reduction of mortality in infective endocarditis
over the past three decades（from 25−30% to 10−20%）may be due mainly to more aggressive surgical intervention based on increased experience. The
indications for surgery3）are now defined more pre-356

Takamiya, Miura, Sako et al

cisely than in the past.9）Since MAIVF complication indicates advanced disruption of tissue at theMAIVF, there is an indication for urgent cardiac
surgery because of evidence of pseudoaneurysm.3）
The present patient had pseudoaneurysm of theMAIVF, so underwent an urgent operation.
要

Therefore, although pseudoaneurysm of theMAIVF is a relatively rare complication of infective endocarditis, it may affect mortality in patientswith infective endocarditis. This point should bekept in mind in patients with suspected vegetation
when echocardiography is performed.
約

急性心不全を合併した感染性心内膜炎における僧帽弁−大動脈弁間の偽性瘤形成
高宮陽介

三浦伸一郎

佐光英人

白井森重徳継忠

朔啓二郎

田 代和之

症例は 22 歳，男性．先天性大動脈二尖弁を合併した大動脈弁閉鎖不全と感染性心内膜炎と診断された．心エコー図法において大動脈弁に疣贅と重度の大動脈弁と僧房弁閉鎖不全を伴い，さらに僧帽弁−大動脈弁間に偽性瘤形成が認められた．臨床症状は，両弁の閉鎖不全により急激な心不全を呈した．僧帽弁−大動脈弁間における偽性瘤形成は，進行した組織破壊を意味しているため，本症例は緊急手術の適応であった．したがって，ただちに大動脈弁置換術と未破裂瘤切除術を実施した．偽性瘤形成は，感染性心内膜炎の合併症としてはまれであるが，心エコー図法により容易に診断できるため，合併症として留意しておくべきである．

J Cardiol 2007 Jun; 49（6）: 353−356

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