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Int J Surg Case Rep
Int J Surg Case Rep
International Journal of Surgery Case Reports
2210-2612
Elsevier

S2210-2612(24)00994-5
10.1016/j.ijscr.2024.110213
110213
Case Report
Left ventricular pseudoaneurysm as a rare catastrophic complication to surgical repair of mitral valve endocarditis
Khattab Mohammad Nasser nasserkhattab@icloud.com
a⁎
Tanous Adeeb b
ALrefai Anas a
Soleman Ragheb bc
a Department of Cardiology, Al Bassel Heart Institute, Damascus, Syria
b Department of Cardiac Surgery, Al Bassel Heart institute, Damascus, Syria
c The general director of Al Bassel Heart Institute, Damascus, Syria
⁎ Corresponding author at: Al Bassel Heart Institute, New Cham, Damascus, Syria. nasserkhattab@icloud.com
28 8 2024
10 2024
28 8 2024
123 11021326 6 2024
20 8 2024
25 8 2024
© 2024 The Authors. Published by Elsevier Ltd on behalf of IJS Publishing Group Limited.
2024

https://creativecommons.org/licenses/by-nc-nd/4.0/ This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
Introduction

Left ventricular pseudoaneurysm (LVPA) is rarely described in the medical literature, as a complication of mitral valve repair after infective endocarditis (IE) and only a few cases have been published until now.

Case presentation

We reported a case of a woman in her forties without past medical history who underwent a successful surgical repair of mycotic pseudoaneurysm at the apex of the left ventricular after two months of mitral mechanical prosthetic valve replacement due to infective endocarditis.

Discussion

Infective endocarditis (IE) remains a rare condition with high associated morbidity and mortality. The rapid and accurate diagnosis with optimal medical therapy in cases of suspected IE is a central challenge of the disease. Delayed diagnosis and initiation of treatment lead to complications and worse clinical outcomes. Fatal cardiac structural complications occur when the infection spreads to the heart and the infection tends to spread through the weakest annular structures, leading to the formation of a paravalvular abscess, fistula, and pseudoaneurysm.

Conclusion

The danger in this condition lies in causing a sudden hemodynamic collapse, which is difficult to treat without emergent surgical intervention. Result in a catastrophic condition and consequences. Therefore, early and rapid diagnosis remains the cornerstone of management.

Highlights

• Infective endocarditis (IE) remains a rare condition with high associated morbidity and mortality.

• IE is an infection of the endocardial surface of any part of the heart, especially the prosthetic or native heart valve or an indwelling cardiac device

• Delayed diagnosis and initiation of treatment lead to complications and worse clinical outcomes.

• IE can cause a variety of histological cardiac and extracardiac complications. Fatal cardiac structural complications occur when the infection spreads to the heart and the infection tends to spread through the weakest annular structures, leading to the formation of a Paravalvular abscess, fistula, and pseudoaneurysm.

• (LVPA) is a rare condition that forms when the LV-free wall ruptures and is contained by pericardial adhesions.

• Mycotic left ventricular pseudoaneurysm is rarely described in the medical literature as a complication of infective endocarditis.

Keywords

Endocarditis
Pseudoaneurysm
Cardiac surgical procedures
Mitral valve
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pmc1 Introduction

Left ventricular pseudoaneurysm (LVPA) is rarely described in the medical literature, as a complication of surgical intervention after infective endocarditis (IE), and only a few cases have been published until now. In this paper, we present a case of successful surgical repair of pseudoaneurysm as a fatal complication after two months of mitral mechanical prosthetic valve replacement due to IE on the native mitral valve [2,3].

2 Case presentation

A woman in her forties, non-smoker, non-alcoholic, with no past medical or surgical history. She suddenly complained of weakness in her lower extremities, which progressed to a paraplegia. This was accompanied by general fatigue, a fever, and several recurring episodes of unconsciousness. The clinical examination revealed the presence of multiple erythematous, painless foci on the lower and upper extremities, consistent with Janeway lesions. Additionally, a 3/6 grade holosystolic murmur was detected at the apex. The rest of the clinical examination was unremarkable. A brain MRI and MSCT diagnosed a bilateral cerebral infarction. A TTE and TEE showed normal LV shape and size with a normal function EF = 65 % and flail anterior mitral leaflet, causing severe mitral regurgitation, along with large vegetation on the posterior mitral leaflet. The blood culture result was positive for Staphylococcus aureus. According to Duke's criteria, the patient was diagnosed with IE on the native mitral valve, leading to the release of infective emboli to the brain, resulting in an ischemic stroke. The patient was treated for three weeks with antibiotics (Vancomycin 1 g and Ciprofloxacin 1 g bid) until the blood culture was negative, and the inflammatory markers stabilized within the normal range. An urgent surgical intervention decision was made to perform a median sternotomy and a trans-right atrial approach under cardiopulmonary bypass. The interatrial septum was opened up to the mitral valve, revealing vegetation on the mitral valve leaflets as well as a rupture of the perivalvular tissue. The valve was completely removed and replaced with a Medtronic (27) mechanical bileaflet prosthetic mitral valve, along with tricuspid valve repair by the DeVega technique. After sending the removed valve leaflets for bacterial culture, complete a two-week course of antibiotic treatment (Vancomycin and Meropenem) following surgery. During this period, the patient fully recovered, and the TTE after three weeks of surgery showed normal results (Fig. 1). Two months after the surgical intervention, the patient developed dyspnea with minimal physical exertion (NYHA class III-IV), along with fatigue and overall weakness, prompting her to seek medical attention at the cardiac clinic. On TTE, a rupture of the LV free lateral wall was observed, with pseudoaneurysm formation measuring 37 × 50 mm on the ruptured part of the LV (Fig. 2). The cardiac MSCT confirmed the diagnosis of a pseudoaneurysm in the left ventricle's lateral wall (Fig. 3). Coronary angiography revealed a normal coronary artery (Fig. 4), ruling out a coronary cause of a pseudoaneurysm as a mechanical complication of MI. And denies the presence of a septic embolus from previous endocarditis vegetation within the coronaries. The emergency surgical decision was made to perform a median sternotomy under cardiopulmonary bypass using dual bicaval cannulation. Adhesions were isolated up to the free wall of the LV, where a large pseudoaneurysm measuring 6 × 8 cm was found on the lateral wall. The pseudoaneurysm had a contact hole with the LV wall measuring 10 × 15 mm. The cavity was emptied of blood, and the aneurysm was completely removed. The orifice was sutured with a Teflon patch, and surgical sutures were spread over three layers (Fig. 5). Upon follow-up, one month after the second surgery, the patient was completely normal. This work has been reported in line with the SCARE criteria [1].Fig. 1 TEE and TTE after three weeks of surgery were completely normal with the normal function of the prosthetic mitral valve without any cardiac mechanical complications.

Fig. 1

Fig. 2 A TTE showed: rupture of the left ventricular free lateral wall with LV pseudoaneurysm formation.

Fig. 2

Fig. 3 Cardiac MSCT confirmed the LV lateral wall pseudoaneurysm diagnosis.

Fig. 3

Fig. 4 A coronary angiography revealed a normal coronary artery.

Fig. 4

Fig. 5 A large pseudoaneurysm was found on the lateral wall of LV, measuring 6 × 8 cm, with a connecting hole to the left ventricular wall measuring 10 × 15 mm. After successful surgical repair of a pseudoaneurysm. The white arrow indicates the free left ventricular wall rupture (ostium of LVPA). The black arrow indicates the outer LVPA wall before surgical removal.

Fig. 5

3 Discussion

Infective endocarditis (IE) remains a rare condition with high associated morbidity and mortality. IE is an infection of the endocardial surface of any part of the heart, especially the prosthetic or native heart valve or an indwelling cardiac device. The healthy cardiac endothelium is resistant to frequent bacteremia; however, after endothelial injury due to several mechanisms, it becomes more susceptible to infection. It is a frequently healthcare-acquired disease, notwithstanding that more than 50 % of cases now occur in patients without known heart disease. The rapid and accurate diagnosis with optimal medical therapy in cases of suspected IE is a central challenge of the disease. Delayed diagnosis and initiation of treatment lead to complications and worse clinical outcomes [4]. IE can cause a variety of histological cardiac and extracardiac complications. One of the most important extra cardiac complications, which indicates poor prognosis of IE, is ischemic CVA due to release of septic emboli from vegetation of the left heart (large vegetation on the posterior mitral leaflet in our case) to the cerebrovascular circulation. Therefore, speed of diagnosis and clinical suspicion are the cornerstones of reducing the rate of complications. LVPA is a rare condition that forms when the LV-free wall ruptures contained by pericardial adhesions. The most common cause of LVPA is myocardial infarction (MI) in more than 50 % of cases, followed by previous heart surgery 30 % as in our patient's case, trauma, and infection the rare cause of approximately less than 5 %. LVPA occurs days to years after MV replacement, when treated medically LVPA has a 48 % risk of rupture. Our case presented a lateral wall LVPA after a prosthetic mitral valve replacement due to IE. Rupture of the left ventricle after mitral valve replacement can present as early rupture, delayed rupture, or late rupture. Late rupture which appears days to years after mitral valve replacement and presents as a pseudo aneurysm of the LV. Another classification of ruptures on the basis of their location on the LV wall to: (1) type-1 rupture is located in the posterior atrioventricular groove; (2) type-2 rupture is in the posterior wall of the LV at the base of the papillary muscle and (3) type-3 rupture is in the area between the atrioventricular groove and the papillary muscle. LVPA have a high mortality and morbidity rate, with a high risk of rupture, potentially leading to fatal complications, particularly among those who do not undergo surgical intervention. Diagnosing LVPA is often challenging due to its atypical presentations. Surgical correction is the treatment of choice for LVPA, and the most frequently preferred surgical method is patch closure which is the method used in our case for surgical treatment of LVPA [[2], [3], [4], [5]].

4 Conclusion

Fortunately, the occurrence of LVPA is very rare, as it is considered one of the most dangerous complications that can occur in patients with mitral valve repair due to IE. The danger in this condition lies in causing a sudden hemodynamic collapse, which is difficult to treat without emergent surgical intervention. Result in a catastrophic condition and consequences. Therefore, early and rapid diagnosis remains the cornerstone of management. Notwithstanding, primary prevention of endocarditis in high-risk patients remains the basis for preventing infection and its complications.

Abbreviations

IE Infective endocarditis

LVPA Left ventricular pseudoaneurysm

EF Ejection fraction

MSCT Multi-slice computer tomography

MRI Magnetic resonance imaging

TTE Transthoracic echocardiogram

TEE Transesophageal Echocardiography

MV Mitral valve

Consent

Written informed consent was obtained from the patient for the publication of this case report and any accompanying investigations. A copy of the written consent is available for review by the Editor-in-Chief of this journal.

Ethical approval

Ethical approval exemption for this study was obtained from the medical director of Al Basel Heart Institute Board of Directors, Damascus, Syria. 10-january-2024. A copy of the ethical approval is available for review by the Editor-in-Chief of this journal.

Funding

None.

Guarantor

Mohammad Nasser Khattab.

Research registration number

Not applicable.

CRediT authorship contribution statement

MNK and AT approached and followed the patient.

RS and AT did the surgical intervention and MNK drafted the initial manuscript. All authors revised the final version of the manuscript and approved it for publication.

Declaration of competing interest

The authors declare no competing interests regarding the publication of this article.
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