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| INTERESTING IMAGES |
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| Year : 2023 | Volume
: 7
| Issue : 1 | Page : 67-68 |
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An Unusual Cause of Heart Failure in a Middle-aged Male
Praveen Gupta, Anunay Gupta, Sandeep Bansal
Department of Cardiology, Vardhman Mahavir Medical College and Safdarjung Hospital, New Delhi, India
| Date of Submission | 23-Sep-2022 |
| Date of Decision | 21-Oct-2022 |
| Date of Acceptance | 22-Oct-2022 |
| Date of Web Publication | 04-Jan-2023 |
Correspondence Address:
Dr. Praveen Gupta
Department of Cardiology, Vardhman Mahavir Medical College and Safdarjung Hospital, Near AIIMS Hospital, Ansari Nagar, New Delhi - 110 029
India
 Source of Support: None, Conflict of Interest: None
DOI: 10.4103/jiae.jiae_48_22
How to cite this article:
Gupta P, Gupta A, Bansal S. An Unusual Cause of Heart Failure in a Middle-aged Male. J Indian Acad Echocardiogr Cardiovasc Imaging 2023;7:67-8 |
How to cite this URL:
Gupta P, Gupta A, Bansal S. An Unusual Cause of Heart Failure in a Middle-aged Male. J Indian Acad Echocardiogr Cardiovasc Imaging [serial online] 2023 [cited 2023 May 29];7:67-8. Available from: https://jiaecho.org/text.asp?2023/7/1/67/367042 |
A 42-year-old male presented with complaints of retrosternal chest pain, dyspnea on exertion, orthopnea, and paroxysmal nocturnal dyspnea for the past 1 month. An ultrasound abdomen done elsewhere showed a large abdominal aortic aneurysm. The chest X-ray at our center showed widening of the mediastinum. A two-dimensional echocardiogram of the patient was performed, which revealed a large descending thoracic aortic aneurysm (TAA), measuring 7.43 cm × 6.17 cm along with a layered thrombus in the parasternal long-axis and apical four-chamber views [Figure 1]a, [Figure 1]b and [Video 1] . The TAA was causing severe compression of the left atrium (LA) and mitral valve (MV). Turbulence was noticed across the MV on the color Doppler echocardiogram with a mean gradient of 8 mmHg. However, the MV was normal in morphology with normal thickness of both the anterior and posterior MV leaflets. The echocardiogram also showed an abdominal aortic aneurysm measuring 8.76 cm × 6.01 cm with a layered thrombus [Figure 1]c and [Video 1]. Both the ascending aorta and aortic arch were normal in size. The patient was advised medical management for heart failure (diuretics) along with aortic aneurysm repair. However, he was lost to follow-up. | Figure 1: Echocardiogram showing thoracic and abdominal aortic aneurysm with the left atrium and mitral valve compression. a and b- The parasternal long-axis and apical four-chamber views showing a large descending thoracic aortic aneurysm, layered thrombus inside the aneurysm, severe compression of the left atrium, and morphologically normal mitral valve with a restrictive opening. c- An abdominal aortic aneurysm is also seen
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[Additional file 1]
Video 1: Echocardiogram of the patient showing aortic aneurysm with the turbulence across mitral valve on color Doppler imaging. The parasternal long-axis and apical four-chamber views are showing descending thoracic aortic aneurysm, layered thrombus, compression of the left atrium, and restricted mitral valve opening. The color Doppler is showing turbulence suggestive of a significant gradient across the mitral valve. The echocardiogram (at the end) is also showing an abdominal aortic aneurysm with a layered thrombus.
The LA is a cardiac chamber located inferoposteriorly in the mediastinum. It has a low intraluminal pressure with a thin wall which predisposes it to compression from surrounding structures. Esophagus and descending thoracic aorta are the most common structures responsible for LA compression. Pulmonary veins that enter into LA from the posterior aspect are also susceptible to compression from the above structures.[1] Ninety-five percent of the patients with TAA are asymptomatic and are usually detected during routine chest X-ray examinations or computerized tomography (CT) for mediastinal widening.[2] The most common presenting symptom in TAA is pain that can be acute due to rupture or dissection or chronic due to compression of surrounding structures.[2] LA compression by TAA, leading to heart failure or hemodynamic compromise, is a rare presentation.[3] LA compression due to an aneurysm may result in reduction in LA volume and a decrease in cardiac output which can lead to hemodynamic instability or cardiogenic shock. Compression of LA also elevates LA pressure which increases pulmonary venous pressure and may precipitate pulmonary edema.[4] MV narrowing and flow obstruction, as seen in our case, would further elevate the LA pressure. All of these lead to symptoms of heart failure, as in our case. Although previously LA compression leading to heart failure has been reported, associated MV compression as seen in our case has never been reported. Echocardiography is a helpful imaging modality in such a scenario; however, CT or magnetic resonance imaging is needed for the detailed evaluation of the aortic aneurysm.[5] Older age, male sex, smoking, hypertension, dyslipidemia, coronary artery disease, family history of aortic aneurysm, connective tissue disorder, Marfan syndrome, Loeys–Dietz syndrome, Ehlers–Danlos syndrome, arteritis, and infections such as syphilis and bicuspid aortic valve are the major predisposing factors for TAA.[2],[5] In the current case, however, the cause of TAA was not apparent.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given his consent for his images and other clinical information to be reported in the journal. The patient understands that his name and initials will not be published and due efforts will be made to conceal his identity, but anonymity cannot be guaranteed.
Acknowledgment
The author would like to thank Dr. Khushboo Srivastava (Vitreoretinal Surgeon, Shubh Netram, Nirman Vihar, New Delhi, India).
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
| References | |  |
| 1. | Van Rooijen JM, van den Merkhof LF. Left atrial impression: A sign of extra-cardiac pathology. Eur J Echocardiogr 2008;9:661-4.  |
| 2. | Kuzmik GA, Sang AX, Elefteriades JA. Natural history of thoracic aortic aneurysms. J Vasc Surg 2012;56:565-71. |
| 3. | Gandhi NM, Greaves M, Brooks NH. Rare case of heart failure caused by compression of the left atrium by a thoracic aortic aneurysm. Heart 2004;90:e9. |
| 4. | DeLuca A, Daniels S, Pathak N. Pulmonary edema due to extreme left atrial compression. N J Med 1991;88:37-8. |
| 5. | Faiza Z, Sharman T. Thoracic Aorta Aneurysm. In: StatPearls. [Internet] StatPearls Publishing; 2022. |
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