Multimodality cardiac imaging of submitral left ventricular aneurysm with concurrent descending aorta mycotic aneurysm

Abstract

We present a case of a 20-year-old Malay man with underlying tuberculous (TB) lymphadenitis who presented with shortness of breath and found to have submitral left ventricular aneurysm (SLVA). SLVA is well recognised but rare. Incidence of SLVA in Malay has never been documented. This is the first reported case of SLVA in Malays with concomitant thoracic aorta mycotic aneurysm. TB has been reported to be associated with SLVA. Treatment is either surgical or conservative. Imaging is required for diagnosis and preoperative assessment. Multimodality imaging include echocardiography (ECHO), cardiac CTangiography and the robust multiparametric cardiac MR (CMR). ECHO is the first line imaging and useful for initial detection of the aneurysm. CMR including the late gadolinium enhancement allows excellent visualisation of the LV aneurysm, tissue characterisation, cardiac function and detection of associated pathology as shown in this case.

Keywords: cardiovascular medicine; radiology; tuberculosis.

Figure 1

(A) 2-D ECHO parasternal long axis view showing the aneurysmal dilatation of the basal inferolateral wall of the left ventricle shown by the grey arrow. (B) Biplane ECHO images showing the submitral LV aneurysm indicated by black arrows. 2-D ECHO, two-dimensional echocardiography; LV, left ventricle.

Figure 2

(A, B, D, E) Saccular aneurysm at the basal inferior wall, submitral in location behind the posterior leaflet of mitral valve, with wide neck measures 2.7 (AP)×5.7 (w)cm. The left ventricle is dilated. (C) Short axis LGE image shows transmural enhancement of the aneurysmal wall in the basal inferior and midinferolateral wall. The pericardium and the wall of the descending thoracic aortic aneurysm are also enhanced. (F) LGE revealed thrombus in the dependant part of aneurysmal sac measuring about 5.2 (w)×3.6 (AP)×1.6 (cc)cm. AP, anterior posterior; LGE, late gadolinium enhancement.

Figure 3

(A, B, D) The aortic root, ascending and arch aorta are of normal calibre. There are saccular lobulated and multiseptated descending thoracic aneurysm extending to the diaphragmatic hiatal level. No periaortic haematoma or evidence of leaking. (C) White blood coronal image showing normal visualised abdominal aorta.

Figure 4

(A) Multiplanar reconstructed LVOT view shows the submitral left ventricular aneurysm. (B) Multiplanar reconstructed VLA view shows the submitral left ventricular aneurysm. (C) Multiplanar reconstructed short axis view shows the submitral left ventricular and descending thoracic aorta mycotic aneurysm. LVOT, left ventricular outflow tract; VLA, vertical long axis.