case_images: PMC10876146_01
case_images: [A] Cardiac-gated CT angiography images: (a) four-chamber view, (b) two-chamber view, (c) oblique sagittal view, and (d) oblique axial view. The images show pericardial effusion (white arrows shown in a, b, and d). Four chambers (a) show pericardial effusion and a mildly dilated left atrium. The two-chamber view (b) shows a ventricular aneurysm (black asterisk) projecting posteroinferior behind the posterior mitral leaflet with a peripheral wall and thrombus. The normal coronaries (rc = right coronary and lc = left coronary) are demonstrated in images (c and d, respectively). Pericardial effusion (white arrow) and pleural effusion (white asterisk) are clearly demonstrated in the image (d). It also shows the prominent pulmonary arteries (on measuring, they were rpa = 22 mm and lpa = 27 mm) suggestive of pulmonary arterial hypertension. [B] Preoperative TTE, parasternal long-axis view, showing a subpericardial echo-free space below the posterior mitral leaflet, that is, a large sub-mitral aneurysm communicating with the left ventricle
case_images: ACA-27-70-g001.jpg
case_images: PMC10876146_01_ACA-27-70-g001.jpg
case_images: aca_39_23-f001
case_images: Other findings included dilated LA (40 mm), a left ventricular internal diameter of 38 mm, and an ejection fraction of 40% [Figure 1B and Video 1]. Computed tomography (CT) angiography confirmed the presence of focal saccular dilation of the left ventricular cavity in the sub-mitral region, with no significant coronary artery disease [Figure 1A].
case_images: Preoperative TTE, parasternal long-axis view, showing a subpericardial echo-free space below the posterior mitral leaflet, that is, a large sub-mitral aneurysm communicating with left ventricle
case_images: ACA-27-70-g002.jpg
case_images: PMC10876146_01_ACA-27-70-g002.jpg
case_images: aca_39_23-f002
case_images: LV were dilated [Figure 2a and b, e and f and Videos 2 and 3]. LA pressure was high with pulmonary vein Doppler, showing reversal of the systolic & Diastolic (S/D) ratio (S < D) with an A-wave duration of 207 ms, mild tricuspid regurgitation (TR), and pericardial effusion [Figure 2d]. Severe MR with two distinct jets contributed to MR, a larger one from LV to SMA and another smaller one from LV to LA [Figure 2c and Videos 4-6].
case_images: (a) Mid-esophageal four-chamber view, with an arrow pointing to the neck of sub-mitral aneurysm (b) Mid-esophageal long-axis view illustrating that the SMA is originating behind the posterior mitral leaflet (arrow) with a well-defined neck. A red asterisk showing neck of sub-mitral aneurysm (c) Mid-esophageal view with color Doppler showing the mitral regurgitation jet into SMA (red arrow) and LA (green arrow) (d) Pulmonary vein Doppler flow, showing reversal of flow, that is, D > S (e) Transgastric view, with deformed LV shape/figure of 8 appearance of LV due to SMA before surgery (f) Transgastric two-chamber view, showing SMA involving the inferolateral wall of LV
case_images: ACA-27-70-g003.jpg
case_images: PMC10876146_01_ACA-27-70-g003.jpg
case_images: aca_39_23-f003
case_images: Severe MR with two distinct jets contributed to MR, a larger one from LV to SMA and another smaller one from LV to LA [Figure 2c and Videos 4-6]. Intraoperatively, a globular swelling of size 5 x 4 cm was observed externally on the posterior wall of the LV [Figure 3a]. A large SMA, with a cavity lined with organized mural clots, was surgically addressed through a trans-aneurysmal ventriculotomy [Figure 3b]. Jude bi-leaflet mechanical mitral valve [Figure 3c].
case_images: Mid-esophageal four-chamber view, showing the opening of sub-mitral aneurysm
case_images: ACA-27-70-g004.jpg
case_images: PMC10876146_01_ACA-27-70-g004.jpg
case_images: aca_39_23-f004
case_images: Severe MR with two distinct jets contributed to MR, a larger one from LV to SMA and another smaller one from LV to LA [Figure 2c and Videos 4-6].