Clinical and echocardiographic features of valvular aneurysms
Authors: Galzerano D , Vriz O , Khalil F , Ur Rehman S , Al Amro B , Jazzar Y , Elmahi I , Di Michele S , Al Sergani A , Alghalayini K , Pergola V , Di Salvo G , Alshaid M 
Published: February 2022

Funding Acknowledgements

Type of funding sources: None.

Introduction

 Valvular aneurysm (VA) is a rare disease whose etiology most frequently includes infective endocarditis but also connective tissue or degenerative myxomatous diseases or traumatism related to a remote surgical procedure. Purpose: Our study aims to describe clinical and echocardiographic features of VA. Methods:  12 years retrospective observational study. Inclusion criteria: patients (pts) found to have a VA by echocardiography (E). A VA was defined as a saccular bulging or a cyst-like outpouching of a valve leaflet that expands and collapses during systole or diastole. The ability of different E techniques in imaging and sizing the valve aneurysm and clinical data were collected. Results: In a 12 years observational period, 12 pts (7 male, 5 female) with a mean age of 41 years ± 16.6 were found to have VA as diagnosed by two experienced readers. In 10 pts there was a diagnosis of IE according to the ESC, AHA criteria. In two pts IE work up was negative. In the patient with definite IE, blood cultures were reported as positive in 7/10 pts (staphylococci 4 pts, Pseudomonas 2 pts, clostridium difficile 1) and 9 pts out of 10 pts underwent surgery and 1 died; all of them had valve replacement except one had mitral valve (MV) repair. Severe regurgitation was found in 9 cases. Associated IE features were: perforation (11 pts), abscess (3pts), vegetation (7pts), fistula (1pt), and embolism (6 pts). Echo features are reported in table 1. Transthoracic E was able to image the VA in only 3/12 pts. Discussion: The spectrum of the VA in our cohort is very unusual. We reported a VA in a bioprosthesis MV not IE related and never described, one case of valvular aneurysm in a bicuspid aortic valve, and 2 cases in the posterior mitral leaflet (PML). The etiology of VA was related to IE as the leading cause (ten in our cohort). In the two pts where no IE was diagnosed, the possible pathogenesis in one patient may have been related to a remote surgical procedure (left atrial dissection) and in the second patient to degenerative phenomena of the MV bioprosthesis. Being the imaging uncommon, it is important to not misinterpret the VA features with large vegetations, cystic lesions, and abscess. Conclusion:  In our series, both the typical spectrum of the disease and less common presentations have been found. We reported one of the largest series of VA with never described unusual presentation. 2-dimensional (D) transesophageal E (TEE) was the key E modalities in the diagnosis integrated by 3D TEE allowing an anatomical imaging useful in surgical decision planning. Almost all cases were associated with perforation and severe regurgitation and a high incidence of embolism. All the cases with IE required surgery except one that died while medical therapy and follow up in the other etiologies . The unusual echocardiographic features have to be as early as possible detected in order to let the patient have the best therapeutical interventions. Abstract Table 1: Echocardiographic features  Abstract Figure. Valvular aneurysm imaging