PSEUDOANEURYSM OF THE MITRAL- AORTIC INTERVALVULAR FIBROSA DUE TO MITRAL ANNULAR CALCIFICATION R. B. Lee DO 1 , M. Bondugula, MD 1 , C. M. Langley RN 2 , P. S. Fail MD 2 , K. Nagendran MD 2 1. Department of Medicine, University Hospital and Clinics, LSU Health, Lafayette, LA. 2. Cardiovascular Institute of the South, Lafayette, LA INTRODUCTION: The mitral-aortic intervalvular fibrosa (MAIF) is part of the cardiac cytoskeleton providing structural integrity to the mitral and aortic valves. This structure is proximal to the anterior leaflet of themitral valve (MV) and gives rise to themitral annulus. Damage to the MAIF due to calcification, endocarditis, ablation, or valve replacement may result in pseudoaneurysm. CASE: An 83-year-old woman with paroxysmal atrial fibrillation, hypertension, and hyperlipidemia presented with dyspnea on minimal exertion. Transthoracic echocardiogram was significant for severe MR with eccentric jet. Transesophageal echocardiogram (TEE) confirmed severe MR but was notable for a billowing structure near the anterior MV leaflet. Computed tomography angiography of the coronaries was performed with a possible aneurysm noted at the base of the MV. A cardiac magnetic resonance imaging (MRI) identified a 2.7 x 2.5 cm pseudoaneurysm of the MAIF. At that time, she was experiencing New York Heart Association Class III symptoms. The decision was made to proceed with possible MV clipping. Via right femoral vein access, a transeptal puncture was performed and the pseudoaneurysm ostium was wired but could not be advanced into the left ventricle. As a result, right femoral artery access was obtained and a wire was passed into the left ventricle. The pseudoaneurysmwas snared from the left atrium and a 10mm vascular plug was inserted for occlusion. After occlusion, a significant reduction in MR was noted intra-operatively and the day post procedure. The patient was noted to have complete resolution of symptoms two weeks later. DISCUSSION: MAIF pseudoaneurysm is a rare and sometimes a fatal complication which can manifest with MR. In this case, the MAIF pseudoaneurysmwas likely due to mitral annular calcification. Multiple imaging studies were required to fully evaluate this anomaly and cardiac MRI ultimately identified it. The pseudoaneurysm was occluded leading to resolution of MR.
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