Download Mitral valve aneurysmal rupture associated with bicuspid aortic

MITRAL VALVE ANEURYSMAL RUPTURE
ASSOCIATED WITH BICUSPID AORTIC
VALVE AND AORTIC VALVE
REGURGITATION
DR.OYA YÜKSEL
PROF.DR.SAİDE AYTEKİN
FLORENCE NIGHTINGALE HOSPITAL
ISTANBUL, TURKEY
A 30-year-old man was admitted to our
hospital because of high grade of fever. Two
weeks before admission he developed
general fatigue and fever. He visited a local
clinic and received antibiotics, but his
symptoms worsened. On admission, his
height was 187 cm and his weight was 75
kg. The blood pressure was 110/60 mmHg.
The first and second heart sounds were
normal. A pansystolic Levine 3/6 murmur at
apex was detected on physical examination.
The transthoracic echocardiography showed
destructive, ruptured aneurysmal anterior
mitral leaflet and severe eccentric mitral
regurgitation, bicuspid aortic valve and mild
aortic regurgitation.
With the transesophageal echocardiograhy,
destructive anterior mitral leaflet, the
oscillating rims of rupture site into left atrium
and the partial chordal rupture of mitral valve
anterior leaflet were seen more clearly.
To enlighten the source of infection,
including the dental examination a systemic
examination was performed and a dental
abscess was detected. The dental abscess
culture and blood cultures were taken. IV
peniciline and gentamycin therapy was
administered. Non-hemolytic group G
streptococcus was detected from both
dental abscess and 12 hours separately
taken blood cultures. The abscess related
tooth was extracted during antibioteraphy.
With the proceeding echocardiography
examinations, the increases in cardiac
dimensions and pulmonary artery systolic
pressure were observed. Subsequently,
mitral valve replacement procedure with the
heart port access method was performed on
the 27th hospital day. A specimen of the
resected mitral valve confirmed a ruptured
mitral anterior leaflet due to endocarditis.
Aneurysm of the mitral valve is most
commonly
associated
with
infective
endocarditis of the aortic valve. The
destruction of the aortic valve results in a
regurgitant jet that strikes the anterior leaflet
of the mitral valve, creating a secondary site
of infection leading to the development of an
aneurysm. These aneurysms may perforate
and result in mitral regurgitation and
pulmonary edema especially in patients with
left ventricular volume overloading from
aortic
valve
regurgitation.
The incidence of mitral valve aneurysm was
found as 9.6% in a group of patients with
left-sided infective endocarditis. Mitral valve
aneurysm without a history of endocarditis is
very rare and usually associated with
connective tissue disorders, myxomatous
valvular degeneration, Marfan syndrome,
pseudoxanthoma elasticum, or physical
stress due to severe aortic regurgitation.
In our patient, in spite of mild aortic valve
degeneration and regurgitation, there was
no definitive echocardiographic evidence of
aortic valve infective endocarditis according
to the Duke criteria. We considered that the
endocarditis could have started from aortic
valve and spread to mitral valve.
In the other hand, because of no definitive
evidence of aortic valve endocarditis, we
assumed that mild aortic regurgitation
causing by bicuspid aortic valve could have
affected mitral anterior leaflet and caused
tissue damage and the infective endocarditis
might have started at that affected point and
caused
aneurysmal
formation
and
eventually rupture. With transesophageal
echocardiography, it was clearly seen that
the aneurysmal rupture site was just at the
aortic regurgitan jet strike site.
The transesophageal echocardiography is
superior
to
the
transthoracic
echocardiograhy in the diagnosis of infective
endocarditis.
The
routine
use
of
transesophageal echocardiography may be
necessary in suspected endocarditis cases.
Vegetations,
abscess
and
aneurysm
formation, chorda or leaflet rupture and
prosthetic valve dehiscence can be easily
detected.
In the absence of surgery to correct valvular
dysfunction, congestive heart failure due to
valvular regurgitation is associated with very
high mortality rates. In our patient,
congestive heart failure due to severe mitral
regurgitation worsened and after proper
length and dose antibiotic therapy, mitral
valve replacement was performed. With
appropriately-timed surgery, this increased
mortality rate can largely be avoided.