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Cardiovascular Anesthesiology: Echo Rounds

Three-Dimensional Transesophageal Echocardiography in the Excision of a Myocardial Pseudoaneurysm

Chang, Guohao MBBS, MRCS, MMed (Surgery)*; Lim, Roy Tet Chen MBBS, MMed (Anesthesia), FAMS; Vu, Thang Duc MD*; Kofidis, Theodoros MD, PD (Ger), FAHA, FAMS*; Ti, Lian Kah MBBS, MMed (Anesthesia), FAMS

Author Information
doi: 10.1213/ANE.0000000000000978

A 52-year-old man with controlled hypertension presented with chest pain and fever of 1 days’ duration. An electrocardiogram showed third-degree heart block, which regressed to second-degree atrioventricular block, Mobitz I. Blood cultures grew Streptococcus agalactiae, likely from dental caries. A transthoracic echocardiogram and coronary angiogram showed no abnormalities. However, magnetic resonance imaging of the heart revealed a myocardial abscess confined to the myocardium and pericardial space, arising from the basal inferior left ventricular myocardium with associated edema and dyskinesia of the basal inferior wall. After 4 weeks of IV penicillin therapy, repeat magnetic resonance imaging showed a decrease in size of the myocardial abscess but a possible breach in the basal inferior myocardium and communication between the left ventricle and the abscess cavity. The patient was referred for urgent surgical intervention. Written consent was obtained from the patient for use of his transesophageal echocardiography (TEE) images.

Preoperative transthoracic echocardiography and intraoperative 2D TEE revealed a cavity measuring 2.8 × 3.6 cm in the right atrium communicating with the left ventricle below the anterior leaflet of the mitral valve, best seen in the midesophageal 4-chamber view (Video 1, Supplemental Digital Content 1, A detailed 2D TEE examination with multiple imaging planes was performed to look for vegetation, fistulization, valvular involvement, or perforation. Color flow Doppler demonstrated biphasic turbulent blood flow from the left ventricle into the cavity through a small orifice measuring 2 mm wide, suggesting a pseudoaneurysm. Pulsatility of the cavity was absent. Trivial regurgitation was seen in both the mitral and the tricuspid valves, whereas the aortic valve was normal. The pseudoaneurysm did not affect transvalvular blood flow across the tricuspid valve and did not obstruct the coronary sinus. There were no vegetations or other abscesses.

Three-dimensional TEE revealed that the pseudoaneurysm communicated with the left ventricle through a single, oval-shaped orifice measuring 2 × 4 mm in diameter (Fig. 1; Video 2, Supplemental Digital Content 2, The precise location of the orifice was shown to be below the posteromedial commissure and not involving the anterior leaflet of the mitral valve.

Figure 1
Figure 1:
Still 3D transesophageal echocardiography (TEE) image of a cut section of the left ventricular outflow tract seen from the left ventricle. The pseudoaneurysm orifice is below the posteromedial commissure of the mitral valve, away from the mitral valve annulus and MAIVF. MAIVF = mitral-aortic intervalvular fibrosa.

Intraoperatively, a large myocardial aneurysm extended from the right atrium into the posterior surface of the heart. The roof of the aneurysm domed inward to the right atrium, reaching the posterior leaflet of the tricuspid valve. There was thinning of the posterior surface of the heart with subepicardial hemorrhage and partial tear on the posterior wall, indicating threatened rupture.

The pseudoaneurysm was occluded and aneurysmal roof plicated (Fig. 2). The aortic and mitral valves were examined, and the coronary sinus and tricuspid valves were tested for competency before closure.

Figure 2
Figure 2:
Illustration of the surgical anatomy and procedure. A, Location of the abscess; B, transverse section of the abscess viewed at the level of the right ventricle; C, posterior view of the abscess; D, enucleation and plication (part 1); E, enucleation and plication (part 2); F, enucleation and plication (completion); and G, transverse section of the repair postenucleation of the abscess.
Figure 3
Figure 3:
Still 2D midesophageal 4-chamber view of the echo dense remnant after enucleation and plication of the pseudoaneurysm.

Postrepair TEE confirmed that the cavity was reduced to an echodense structure (Fig. 3). Left ventricular contractility was preserved, and there was no worsening of the mitral and tricuspid valve regurgitation. The patient made an uneventful recovery and was discharged home on the ninth postoperative day.


De novo infection and formation of a myocardial abscess at the mitral valve level is extremely rare.1 This happens more commonly because of contiguous spread from an infection in the aortic valve because of its close anatomical relationship to the mitral-aortic intervalvular fibrosa (MAIVF).2 Infection of the myocardium is associated with serious complications, including compression, fistula formation, and perforation, and prompt diagnosis is important to reduce perioperative mortality and morbidity.1,2

Two-dimensional echocardiography is the preferred imaging modality used in the diagnosis of a ventricular pseudoaneurysm.3 Reports of 2 previous Echo Rounds demonstrated the utility of intraoperative 2D TEE in distinguishing pseudoaneurysms from true aneurysms4 and assessing the subvalvular mitral valve apparatus and functional mitral regurgitation.5 Multiplane assessment of the pseudoaneurysm can reveal important information regarding the extent and spread of the underlying infection.6

Our report illustrates the impact of additional anatomical information provided by 3D TEE on the surgical procedure. The MAIVF is a triangular region bounded by the right and left fibrous trigones with the anterior mitral valve leaflet suspended in-between. This forms the fibrous continuity of aortic and mitral valves, and because of its avascular nature, it is prone to infection.2 Any infection involving the MAIVF is best seen on 2D TEE as a thickening or an echo-free space in the midesophageal long- and short-axis aortic valve views.6 The presence of pulsatility is a distinct echocardiographic feature of pseudoaneurysms of the MAIVF.2 The thin nature and fragility of the MAIVF lends itself to tears, which can be seen on the en face views using 3D TEE.7 In our patient, 3D TEE demonstrated that the pseudoaneurysm was located away from the MAIVF and the en face appearance of the surface of the MAIVF was normal, suggesting that the abscess had ruptured into the left ventricle directly and did not track along the mitral annulus toward the MAIVF. In addition, if the pseudoaneurysm had ruptured into the right atrium, it would create a direct left ventricular-to-right atrial shunt, otherwise known as a Gerbode defect.8 The Gerbode defect is a rare congenital cardiac anomaly, which is characterized by a left ventricular-to-right atrial communication and the presence of a high Doppler gradient across the defect, most commonly resulting from a ventricular septal defect. In our patient, the TEE demonstrated a pseudoaneurysm in the right atrium that communicated with the left ventricle but not into the right atrium.

Surgical management involves enucleation and plication of the pseudoaneurysm. In our patient, the demonstrated noninvolvement of the MAIVF and precise localization of the orifice with 3D TEE guided the surgeon to access the aneurysm via the right atrium. In addition, the location of the orifice allowed plication to be performed through the aortic valve from the aorta. This is technically less demanding and less invasive than accessing the orifice through the left atrium, which typically would have been performed if either the mitral valve or the MAIVF was suspected of being infected.

In conclusion, the use of 3D TEE greatly complemented 2D TEE in providing important anatomical information that impacted the surgical management of the pseudoaneurysm.

Clinician’s Key Teaching Points

By Nikolaos J. Skubas, MD, Kimberly Howard-Quijano, MD, and Martin J. London, MD

  • Infective endocarditis often begins on valves and may spread into the neighboring myocardium, where it can lead to abscess formation. Abscesses can be complicated by possible compression of neighboring anatomic structures, valvular dysfunction, communication with intracardiac chambers via fistula tracts, or rupture into the pericardial space. A common site of infection is the mitral-aortic intervalvular fibrosa (MAIVF), an avascular fibrous area between the aortic annulus and the base of the anterior mitral leaflet.
  • Myocardial abscess on transesophageal echocardiography (TEE) can be diagnosed as an abnormal left ventricular (LV) mass or echo-free space adjacent to the aortic valve in the midesophageal short- or long-axes. A MAIVF abscess may evolve into a myocardial pseudoaneurysm, which is a pulsatile cavity contained only by the epicardium.
  • In this case, the patient presented with a myocardial abscess and dyskinesia of the basal inferior LV wall on preoperative magnetic resonance imaging. A nonpulsatile space with thin borders was imaged inside the right atrium with 2D TEE. Color Doppler demonstrated bidirectional communication with the LV. The low velocity communication excluded a LV-to-right-atrium ventricular septal defect, and the small orifice was typical of a pseudoaneurysm. Neither the tricuspid nor the mitral valves were affected. Three-dimensional TEE imaging from the LV perspective revealed the location of the communicating orifice to be adjacent to, but not involving, the MAIVF.
  • It is important to delineate the anatomy of any cavity communicating with the LV because it may direct surgical management. In this case, the cavity was repaired via the right atrium and the communicating orifice was closed via a transaortic valve approach.


Name: Guohao Chang, MBBS, MRCS, MMed (Surgery).

Contribution: This author helped write the manuscript.

Attestation: Guohao Chang approved the final manuscript.

Name: Roy Tet Chen Lim, MBBS, MMed (Anesthesia), FAMS.

Contribution: This author helped write the manuscript.

Attestation: Roy Tet Chen Lim approved the final manuscript.

Name: Thang Duc Vu, MD.

Contribution: This author helped write the manuscript.

Attestation: Thang Duc Vu approved the final manuscript.

Name: Theodoros Kofidis, MD, PD (Ger), FAHA, FAMS.

Contribution: This author helped write the manuscript.

Attestation: Theodoros Kofidis approved the final manuscript.

Name: Lian Kah Ti, MBBS, MMed (Anesthesia), FAMS.

Contribution: This author helped write the manuscript.

Attestation: Lian Kah Ti approved the final manuscript.

This manuscript was handled by: Martin London.


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