|INTERESTING CASE REPORT
|Year : 2023 | Volume
| Issue : 1 | Page : 51-53
Pericardial Patch Aneurysm following Repair of Atrioventricular Septal Defect and Mitral Valve Replacement with 10-Year Follow-Up
Madhu Shukla, Jagdish Chander Mohan
Department of Cardiology, Institute of Heart and Vascular Diseases, Jaipur Golden Hospital, New Delhi, India
|Date of Submission||14-Dec-2022|
|Date of Decision||10-Jan-2023|
|Date of Acceptance||11-Jan-2023|
|Date of Web Publication||25-Feb-2023|
Prof. Jagdish Chander Mohan
A51, Hauz Khas, New Delhi - 110 016
Source of Support: None, Conflict of Interest: None
A 26-year-old female patient who had surgical closure of the ventricular septal defect with an autologous pericardial patch and mitral valve repair for the cleft mitral valve in early childhood at age 4 and then subsequently mitral valve replacement with a bioprosthetic valve in 2011 at the age of 16 years, was found to have a large cystic mass protruding into the right ventricular inflow on echocardiography during a late routine examination in 2012. The cystic mass identified on echocardiography was shown to be an aneurysmal dilatation of the autologous pericardial patch used for the repair of the ventricular septal defect. As the third corrective surgery would have been inherently complicated with risk to the conduction system, she has been followed conservatively for the last 10 years without any significant complaints except mild dyspnea. This case illustrates that the pericardial patch aneurysm is relatively stable and surgery is rarely indicated unless the aneurysm causes mechanical compression or obstruction of the right ventricular inflow or outflow.
Keywords: Mitral valve replacement, patch aneurysm, ventricular septal defect
|How to cite this article:|
Shukla M, Mohan JC. Pericardial Patch Aneurysm following Repair of Atrioventricular Septal Defect and Mitral Valve Replacement with 10-Year Follow-Up. J Indian Acad Echocardiogr Cardiovasc Imaging 2023;7:51-3
|How to cite this URL:|
Shukla M, Mohan JC. Pericardial Patch Aneurysm following Repair of Atrioventricular Septal Defect and Mitral Valve Replacement with 10-Year Follow-Up. J Indian Acad Echocardiogr Cardiovasc Imaging [serial online] 2023 [cited 2023 Sep 27];7:51-3. Available from: https://jiaecho.org/text.asp?2023/7/1/51/370600
| Introduction|| |
The autologous pericardium, treated or fresh, is preferentially used in reconstructive cardiovascular surgery in children because it is viable with growth potential. It expands in tandem with the growth of children with minimal subsequent calcification, low risk of endocarditis, and no immunogenicity. However, rarely it can expand exponentially with aneurysmal dilatation of the patch with or without obstruction.,, This report describes nearly 10-year relatively asymptomatic follow-up of a young girl with a large aneurysm of the pericardial patch protruding into the right ventricular inflow.
| Case Report|| |
This thin-built 26-year-old female patient (weight 42 Kg and height 162 cm) was diagnosed with incomplete atrioventricular septal defect at the age of 4 years. She had surgical closure of the ventricular septal defect with an autologous pericardial patch and mitral valve repair for the cleft mitral valve in early childhood and then subsequently mitral valve replacement with a bioprosthetic valve in 2011 at the age of 16 years. One year later, on routine echocardiographic evaluation, she was found to have an atrioventricular septum aneurysm (3.2 cm × 2.8 cm). She was followed conservatively till June 2021 when she underwent cardiac computed tomography and a detailed transthoracic echocardiographic examination. Physical examination showed supine resting blood pressure of 100/70 mmHg, regular pulse rate of 90 beats/min, normal heart sounds, and no murmur. A 12-lead electrocardiogram showed sinus rhythm, left axis deviation, and incomplete right bundle branch block. The chest skiagram showed mild enlargement of the cardiac silhouette. Her routine biochemical tests were normal. Transthoracic parasternal long-axis view showed an expansile ovoid cystic mass (3 cm × 2.8 cm in systole) anterior to the left atrium and adjacent to the ring of the prosthetic mitral valve. This cystic mass showed to-and-fro flow on the color flow map [Figure 1], [Video 1] and [Video 2]. Its outer wall was thin and noncalcific and it protruded into the right atrioventricular junction distorting the right atrial and right ventricular cavity on computed tomographic imaging [Figure 2] and [Figure 3]. The attachments to the margins of the ventricular septal defect (shown as "neck" of the aneurysm) were intact, and there was no obvious left-to-right shunt through the material of the patch. No tricuspid valve regurgitation or obstruction was noted on the color flow Doppler examination. The aneurysm was in proximity to the atrioventricular septum, mitral prosthesis, and tricuspid valve [Figure 4] and [Figure 5]. The mitral bioprosthesis was functioning normally, and biventricular systolic function was normal.
|Figure 1: Modified parasternal long axis view showing a cystic mass anterior to prosthetic mitral valve with a narrow neck (yellow arrow) and to-and-fro flow (a and b). LA: Left atrium, LV: Left ventricle, PSA: Pericardial patch aneurysm, RV: Right ventricle|
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|Figure 2: (a) Aneurysm in the short-axis view with narrow neck and thin wall in relation to basal septum. (b) Apical four-chamber view showing the cystic structure to be close to mitral and tricuspid valves protruding into the right atrium. Yellow arrow points to the neck of the aneurysm. LA: Left atrium, LV: Left ventricle, RA: Right atrium, RV: Right ventricle|
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|Figure 3: Computed tomographic sections in axial and sagittal views showing the AN projecting into the right atrioventricular groove and distorting the right inflow. AN: Aneurysm, AO: Aorta, LA: Left atrium, LV: Left ventricle, RA: Right atrium, RPA: Right pulmonary artery, RV: Right ventricle|
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|Figure 4: Schematic diagram showing relationship of the aneurysm to the valves. Black arrow points to site of aneurysm in relation to the three cardiac annuli. MV: Mitral valve, TV: Tricuspid valve|
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|Figure 5: Computed tomographic coronal view showing relationship of the AN with cardiac structures. Distortion of the right atrial cavity is also seen. AN: Aneurysm, AO: Aorta, LV: Left ventricle, PA: Pulmonary artery, PMV: Prosthetic mitral valve, RA: Right atrium|
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[Additional file 1]
Video 1: Patch aneurysm in the apical 4-chamber view
[Additional file 2]
Video 2: Parasternal long-axis view showing the patch aneurysm. LV: Left ventricle, MV: Mitral valve, PSA: Pericardial patch aneurysm
Based on the imaging findings, the absence of clinically significant right atrial or ventricular obstruction, and the patient's relative lack of symptoms, the multidisciplinary heart team and the family decided on conservative management with yearly clinical and echocardiographic follow-up.
| Discussion|| |
An autologous pericardial patch is the preferred material for closing intracardiac defects and for the repair of outflow tracts because of its durability and viability. Rarely, these patches become redundant and show aneurysmal deformation.,,,, Pericardial patch-defect size mismatch and large-sized patches have been proposed as the major risk factors for developing a pericardial patch aneurysm.,,, As such, autologous pericardium is less user-friendly than other patch materials because it is sticky and lacks stiffness. It has to be properly sized to prevent aneurysmal dilatation. This patient developed a large patch aneurysm without any obstruction or valvar deformity sometime after the second surgery. The present case suggests that the development of pericardial patch aneurysm may occur very late as shown previously. Furthermore, pericardial patch aneurysm may be relatively stable as in this case and also reported previously and surgery is rarely indicated unless the aneurysm causes mechanical compression or obstruction of the right ventricular inflow or outflow.
| Conclusion|| |
Larger than the required autologous pericardial patch used for repair of defects such as ventricular septal defect can rarely become redundant and aneurysmal. Such patch aneurysms can cause compression of adjoining structures or may remain asymptomatic.
The patient presented with acute pulmonary edema in end-December 2022 and had degenerated bioprosthetic leaflets with moderate mitral regurgitation and mean diastolic transprosthetic pressure gradient of 34 mmHg.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given her consent for her images and other clinical information to be reported in the journal. The patient understands that her name and initials will not be published and due efforts will be made to conceal her identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]