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Univers
ity of
Cap
e Tow
n
.. I
i I
• •
II
I I
The copyright of this thesis vests in the author. No quotation from it or information derived from it is to be published without full acknowledgement of the source. The thesis is to be used for private study or non-commercial research purposes only.
Published by the University of Cape Town (UCT) in terms of the non-exclusive license granted to UCT by the author.
Univers
ity of
Cap
e Tow
n
Univers
ity of
Cap
e Tow
n
2
Univers
ity of
Cap
e Tow
n
3
H IS'll"'" 1"'"
Univers
ity of
Cap
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n
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cases. rna
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at
Univers
ity of
Cap
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n
M3 8M
K 9F
1M 12 F
:K1 9M
1M2 31 F
M B Grade 3
sM B
oK M B Grade 3 and 3+
~N 30 F B 2 -3 and 2+ Mitral
~K2 5M and 2+ Mitral Endocarditis' 2
,M 28 M B 3
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ity of
Cap
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Cap
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n
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Cap
e Tow
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34 M 2+
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ity of
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Univers
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Cap
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JM 31 F
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fibrous tissue the wall of contains some fibrin. No
inflammation seen. Features consistant :nn,n""""T~1 Submitral
and
material and
, chronic non
18
Heart
Univers
ity of
Cap
e Tow
n
was
a
.( 1
seen.
none
15
or
19
it
venous
were no
5
recurrence.
are a
Univers
ity of
Cap
e Tow
na one
occurs
were seen
same
causes
20
as
or
Univers
ity of
Cap
e Tow
n
22
a ra
or
a or il a gross
ure 1)
With " ... '"n' ....... ''''' John W Barlow
/-'PI"c;nprr'IVI"C; on the Mitral valve
Section 2 183
Univers
ity of
Cap
e Tow
n
[1
ca
a
exa
ue
a
as
are common causes
a
a
or
ca
in
is a
23
ilure
] or
reveal
d
n
*].
are
Univers
ity of
Cap
e Tow
nsac.
With "":"',,,,,,' John W Barlow
I-'er'SDf'.!CClIVeS on the Mitral valve
6, Section 2 183
N
is a
is a
Univers
ity of
Cap
e Tow
n
25 present only if the aneurysm is not of recent origin [14,1 *]. The lung
fields may commonly demonstrate upper lobe diversion of pulmonary
blood flow consistent with pulmonary venous congestion.
(Figure 3) Postero-anterior (A) and lateral (8) chest radiograph of a 64
year old woman, showing large multiloculated calcified submitral
aneurysm. (Arrows)
With permission: John W Barlow
Perspectives on the Mitral valve
Chapter 6, Section 2 Page 183
2. Electrocardiographical Features
The ECG is normal in a minority of cases, and Chessler found only one
completely normal ECG in 15 patients with submitral aneurysms [2].
Electrocardiographical evidence of left ventricular hypertrophy, out of
proportion to the severity of the mitral regurgitation, may suggest the
possibility of an additional hemodynamic load on the left ventricle [1 *].
Low voltages, nonspecific ST -segment and T-wave changes and signs of
myocardial ischaemia or infarction may be encountered.
Electrocardiographical evidence of ischaemia is often due to distortion or
obstruction of the left circumflex coronary artery along its course in the
atrioventricular groove [4,9,13]. Patients presenting with ventricular
tachycardia have also been encountered [4]. Atrial fibrillation is also
common due to the left atrial enlargement [14J.
Conduction disturbances such as first-degree heart block are not
uncommon and may also be related to myocardial ischaemia produced by
Univers
ity of
Cap
e Tow
n
on a
rams
ca
corona a
is necessa to assess
ure 4
26
if it is
or
a
Univers
ity of
Cap
e Tow
n
27
A
B
(Figure 4 A, B) (A) Angiogram in the right anterior oblique position. (B)
Angiogram in the Left lateral position, both demonstrating a LVSMA.
(AO) Aorta, (LV) Left ventricle, (AN) Aneurysm, (LA) Left atrium, (T)
Thoracic aorta. The arrows in (B) demonstrates the calcified rim of the
LVSMA
With permission: John W Barlow
Perspectives on the Mitral valve
Chapter 6, Section 2 Page 183
Univers
ity of
Cap
e Tow
n
28
4. Echocard iographic Features
2-D echocardiography demonstrates a submitral aneurysm as an echo
free space arising below the posterior mitral leaflet extending postero
medially and superiorly to compress the left atrial cavity. Communication
with the left ventricular cavity can then be seen in the region of the
atrioventricular groove. The mitral valve apparatus is very well visualized
and mitral incompetence can readily be demonstrated. Mitral
incompetence is usually due to lack of leaflet co-aptation and distortion of
the mitral valve. Because of cardiac displacement and variable position of
the aneurysms, unconventional views are sometimes necessary to
demonstrate them. Left ventricular (LV) contrast echocardiography can
also be used [23]. A pigtail catheter is placed in the LV and the patients
blood is used as the contrast agent to determine mitral regurgitation and
to locate the neck of an aneurysm. A flail posterior leaflet provides
important ancillary evidence of the existence of a submitral aneurysm,
provided that other causes such as degenerative myxomatous disease,
trauma, infective endocarditis, and acute rheumatic carditis have been
excluded.
Fig 5 A
Univers
ity of
Cap
e Tow
n
29
A
B
c Fig 5 B
(Figure 5 A,B) 2-D echocardiography pictures demonstrating two different
patients with LVSMA. The LVSMA is seen as an echo-free space arising
below the posterior mitral leaflet extending postero-medially and
superiorly to compress the left atrial cavity. (Ao) Aorta, (LA) Left atrium,
(MV) Mitral valve, (An) Aneurysm, (LV) Left ventricle, (N) Neck of
aneurysm, (AL) Anterior leaflet on mitral valve, (PL) Posterior leaflet of
mitral valve
Univers
ity of
Cap
e Tow
n
30 5. Computed Tomography (CT)
The use of CT and contrast CT in defining the position, size, presence and
extent of thrombus and calcification has represented a major advance in
the diagnosis and assessment of submitral aneurysms. Barlow reports
that CT was positive in all seven patients in whom it was performed, and
the information obtained equaled or surpassed that derived from
angiography [1 *]. CT provides an excellent non-invasive method of
investigation in suspected cases of submitral aneurysm.
A
---~---
Univers
ity of
Cap
e Tow
n
31
B
(Figure 6) A) Consecutive contrasted Computed tomography (CT) scan in
a 31 year old male demonstrating the (A) aneurysm and its
communication, via a wide neck (N) with the left ventricle (LV) Extensive
thrombus formation is seen in the aneurysm.
(Figure 6) B) Single frame of CT scan sequence clearly demonstrating the
LVSMA (AN) in relation to the aorta (AG), left ventricle (LV) and the left
atrium (LA).
With permission: John W Barlow
Perspectives on the Mitral valve
Chapter 6, Section 2 Page 183
--------
Univers
ity of
Cap
e Tow
n
32 ~~~------------------
is
or an a severe
[ ],
1] his
was cause
was an
or
or a small
a
if are is
Univers
ity of
Cap
e Tow
n
SDi:jCt::S are
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d
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m
or
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Univers
ity of
Cap
e Tow
n
sca is common.
a two
is
Univers
ity of
Cap
e Tow
nFrom
uences
usua
a
( 8
Abrahams DG, Barton 0, Cockshot WP,
Annular Subvalvar left ventricular aneurysms
Q J Medl :345-360
ann
a
some
as seen
is
35
a
if
a rams.
Univers
ity of
Cap
e Tow
n
36
A
(Figure 8 A) : Left Ventriculograms in the right anterior oblique plane.
LVSMA expanded and involving the whole mitral annulus as found in two
of the patients in Group III. Contrast medium has been injected into the
left ventricle (LV) via the aortic root (A). The contrast media is seen filling
the LV and the left atrium (LA) indicating severe mitral incompetence. The
LVSMA (AN) is outlined with the dashed line.
Fig A: With Permission: H.J. Du Toit et al.
Interactive Cardiovascular and Thoracic Surgery 2 (2003) 547-
551
Aneurysms tend to be large as shown in the intra-operative photograph
because they track in a circular direction. Enlargement is laterally,
anteriorly and superiorly by herniation through the attachment of the left
ventricular muscle and the fibrous valve ring. They may be loculated and
in all instances contain clot, fresh and laminated, as well as cellular debris.
Calcification of the laminated clot may develop
(Figure 9)
Univers
ity of
Cap
e Tow
n
37
(Figure 9): Intra-operative photograph of a LVSMA, shown here as the
whitish bulging structure to the left of the image. The aortic cannula
(cranial) is seen in the centre bottom of the photograph and the
diaphragm at the top (caudal) Arrows indicating LVSMA
The left atrium may be compressed and the circumflex artery may be
greatly stretched and narrowed along its course in the atrio-ventricular
groove by the aneurysm. This may produce symptoms of angina pectoris
and may lead to myocardial infarction due to coronary artery occlusion or
thrombosis.
(Figure 10,11)
Univers
ity of
Cap
e Tow
nCOn?.oress eel. c/rc ", .. 72£.160 x
arterY'
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(Figure 10) Diagrammatic representation of stretching and compression
38
of the circumflex coronary artery by the enlarging aneurysm. A) Reflection
of the pericardium demonstrating the relationship of the cardiac
structures. B) Saggital view of the LVSMA. C) Compression of the
circumflex coronary artery by the aneurysm
From: Clerkin lP, Bunje H
Rare cardiac aneurysm in a young adult
Thorax 1955;10:42-45
Univers
ity of
Cap
e Tow
n
39
(Figure 11) Angiogram of the Left coronary system in the right anterior
oblique plane. Stretching and partial occlusion of the circumflex artery is
demonstrated (lower right of picture)
From : Clerkin JP, Bunje H
Rare cardiac aneurysm in a young adult
Thorax 1955;10:42-45
Univers
ity of
Cap
e Tow
n
an exc:es;slv'e
or
su
i.
severe
are in
an
if cause
a
an
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[ is
A
Univers
ity of
Cap
e Tow
n
or a
n
an
MJ Antunes
Submitral Left Ventricular
J Thoracic Cardiovasc
41
a
1
Univers
ity of
Cap
e Tow
n
43
(Figure 13) Intra-operative photograph of extra-cardiac approach. The
forceps and eyelid retractor are in the aneurysm cavity_ A patch of
autologous pericardium is being sewn into place
Univers
ity of
Cap
e Tow
n
1 cases
to a
as as a a
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ity of
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Cap
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n
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