A case of mycotic aneurysm of the sinus of Valsalva with a hemodynamic pattern simulating mitral stenosis
Kobayashi, A.; Sugimura, S.; Suenaga, Y.; Katsuragawa, K.; Watanabe, K.; Mukaiyama, H.; Hirai, T.; Moriura, S.; Sugiura, M.; Suzuki, M.
Nihon Kyobu Geka Gakkai 30(2): 247-255
1982
ISSN/ISBN: 0369-4739 PMID: 6896523 Document Number: 185759
A case of mycotic aneurysm of the sinus of Valsalva is reported which simulated severe mitral stenosis clinically. A 48 yr old female had gradual development of nocturnal dyspnea, without any episode of febrile illness. Symptoms of congestive heart failure (CHF) gradually worsened and she was admitted to the hospital in Sept. 1979. While in the hospital she had an episode of fever and a blood culture at this time grew out Bacillis subtilis, but contamination was strongly suspected. Physical findings were those of acute aortic insufficiency and the patient was treated for CHF and underwent antibiotic therapy. Despite intensive medical therapy, cardiomegaly progressed and the right pleural effusion failed to clear. UCG findings were atypical. An echo resembling an aneurysm of the sinus of Valsalva was recorded in subaortic area and it protruded in the outflow tract of the left ventricle in diastolic phase. The movement of anterior mitral leaflet was severely limited by its impingement. Cardiac catheterization findings showed severe aortic regurgitation and mitral stenosis. Angiography showed findings suggestive of a sinus of Valasalva aneurysm and its impingement on the anterior mitral leaflet. Because of these findings the patient was submitted to open cardiac operation, with the intent of excising the aneurysm and correct aortic regurgitation. At operation, apparent inflammatry change of aortic valve was clarified by small contracted left coronary cusp and somewhat thickened and friable right cusp. An abscess opening was present just outside the line of attachment of left cusp, and a sac-like endocardial bulge was seen in the outflow tract of the left ventricle. The inlet to the myocardial abscess cavity was closed, the aneurysm was partially excised and plicated, and the aortic valve was totally excised except for the left coronary cusp and was replaced by a Starr-Edwards model 2400, size 9-A ball valve prosthesis. The mitral valve was grossly intact as examined from above through the aortic orifice. Postoperative the patient did well and was relieved of CHF. Postoperative echocardiography showed normal mitral valve motion and the abormal echo in the subvalvular area was no longer seen. The pathogenesis and treatment of the mycotic aneurysm of the sinus of Valsalva were discussed and the usefulness of echocardiography in diagnosing these lesions was emphasized.