Subannular left ventricular pseudoaneurysm following mitral valve replacement

Delayed development of left ventricular pseudoaneurysm is a rare late complication of mitral valve prosthesis and requires early surgical intervention. Here we describe the occurrence of such a complication diagnosed 6-months after the valve surgery in an elderly lady. We discuss the anatomic delineation of subannular left ventricular pseudoaneurysm using multiple imaging modalities including CT angiography.A 60-year old lady underwent mitral valve replacement (MVR) with 28-Starr-Edward prosthesis in December 2005 for severe calcific mitral stenosis in our institute. She had also received saphaneous vein graft for a borderline lesion in mid left anterior descending artery (LAD) concomitantly. She was asymptomatic on follow up. Routine follow up transthoracic echocardiogram at 6-months postoperatively suggested a cavity at left atrioventricular groove communicating with the left ventricle (LV) at the posterobasal region of LV. Chest radiograph (posteroaanterior view) showed a rounded opacity silhouetting the left cardiac border (Figure 1). Transesophageal echocardiography (TEE) clearly delineated a 50 × 50 mm cavity filled with spontaneous echo contrast posterolateral to LV (Figure 2) beneath the left upper pulmonary vein. There was no turbulence demonstrable in the pulmonary veins. The aneurysm was communicating with left ventricular cavity through a 14 mm rent in the LV wall situated 7 mm away from the mitral annulus in horizontal and vertical midesophageal views. The walls of the cavity appeared to be formed only by pericardium suggesting a pseudoaneurysm of left ventricle. Mild paravalvular mitral regurgitation was also noted lateral to the prosthesis. No turbulence was noted in left pulmonary veins to suggest extraluminal compression. A computerized tomographic angiography (CTA) with 3-D reconstruction was done for better delineation prior to cardiac catheterization, which confirmed the site and size of the aneurysm. Left lower pulmonary vein (LLPV) (fig 3) and