(Circulation. 2000;102:2159.)
© 2000 American Heart Association, Inc.
Images in Cardiovascular Medicine |
Severe Mitral Regurgitation After Valve Replacement as Cause of Pulmonary Venous Aneurysm
From the Franz Volhard Clinic and Max-Delbrück Center for Molecular Medicine, Charité, Campus Berlin-Buch, Humboldt University of Berlin, Berlin, Germany.
Correspondence to Steffen P. Christow, MD, Franz Volhard Clinic, Charité, Campus Berlin-Buch, Wiltbergstraße 50, 13125 Berlin, Germany. E-mail christow{at}fvk-berlin.de
A4 9-year-old man
was referred because of an acute myocardial infarction. He had
undergone aortic and mitral valve replacements for endocarditis in 1984
(Figure 1
). In the early 1990s, the
mitral valve had developed a paravalvular leak that was not
regarded as consequential. A right-sided mass was noted on the chest
roentgenogram, however, that was interpreted as a pericardial
"cyst." The patient denied trauma, vasculitis, syphilis, and
chronic granulomatous diseases and had not been known to have a
pericardial cyst previously. On admission, the chest roentgenogram
demonstrated cardiomegaly and a well-circumscribed circular mass
adjacent to the right cardiac border (Figure 2). Transthoracic
echocardiography demonstrated an enlarged right
pulmonary vein (Figure 3, arrows). Color Doppler studies revealed 2 paravalvular
leaks flanking the mitral valve prosthesis; the larger septal
jet extended into the right pulmonary vein. CT confirmed the
presence of a true aneurysm involving the right
inferior pulmonary vein (Figure 4, arrows).
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True aneurysms of the pulmonary vein are rare, and little is known about their pathogenesis.1 However, an association between such aneurysms and mitral regurgitation has been described.1 2 3 Our patient’s lesion developed subsequent to his valve replacement and paravalvular regurgitation. The pathogenesis is believed to involve the force vector of blood flow from the left ventricle to the left atrium, targeting the right inferior pulmonary vein. This notion is supported by the higher wedge pressure V wave (48 versus 34 mm Hg, respectively) we observed when catheterizing the patient’s right compared with his left pulmonary vein. The same mechanism is held responsible for the right upper lobe pulmonary edema occasionally observed accompanying mitral regurgitation.4
Footnotes
The editor of Images in Cardiovascular Medicine is Hugh A. McAllister, Jr, MD, Chief, Department of Pathology, St Luke’s Episcopal Hospital and Texas Heart Institute, and Clinical Professor of Pathology, University of Texas Medical School and Baylor College of Medicine.
Circulation encourages readers to submit cardiovascular images to the Circulation Editorial Office, St Luke’s Episcopal Hospital/Texas Heart Institute, 6720 Bertner Ave, MC1-267, Houston, TX 77030.
References
1.
Sirivella S, Gielchinsky I.
Pulmonary venous aneurysm presenting as a
mediastinal mass in ischemic
cardiomyopathy. Ann Thorac Surg. 1999;68:241–243.
2. Gabriele OF, Hood WP. Aneurysm of left atrium. Radiology. 1970;97:397–398.[Medline] [Order article via Infotrieve]
3. Shida T, Ohashi H, Nakamura K, et al. Pulmonary varices associated with mitral valve disease: a case report and survey of the literature. Ann Thorac Surg. 1982;34:452–456.[Abstract]
4.
Gurney JW, Goodman LR. Pulmonary edema
localized in the right upper lobe accompanying mitral
regurgitation. Radiology. 1989;171:397–399.
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