University of Cape Town

Transcription

1 .. I i I II I I

2 The copyright of this thesis vests in the uthor. No quottion from it or informtion derived from it is to be published without full cknowledgement of the source. The thesis is to be used for privte study or noncommercil reserch purposes only. Published by the (UCT) in terms of the non-exclusive license grnted to UCT by the uthor.

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6 cses. rn on 5 p

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9 ws re r

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11 2 venous cses. 10 c rn n is ws ex I groove ws rn n h it is usu were I. scs were U

12 11 1 1] men 17 ± 6 some m u ul were were were d r 1] (i c eli ws 16 seven were in ). cre to severe d t

13 M3 8M K 9F 1M 12 F :K1 9M 1M2 31 F M B Grde 3 sm B ok M B Grde 3 nd 3+ ~N 30 F B 2-3 nd 2+ Mitrl ~K2 5M nd 2+ Mitrl Endocrditis' 2,M 28 M B 3,/IN 10: B 1 34 M B ii1h 32 M B 4 ii1b 15 M B ne nd 3+ Mitrl incom 3

14 13 (n=3) (n=l s d re nnulus (n=5) l [ nnulus were s 2 M roup I 15 es: in c in seven 1-17 I v

15 14 men ± =.::...::::..::::::_= were ± ~~~ - 12 ± ws common or ure com se.

16 one d 15 versus ws I were

17 34 M 2+ II 11 F 4+ o 3+ o

18 17 o ws no Inl,..'"'' ws no ws

19 18 JM 31 F fibrous tissue the wll of contins some fibrin. No inflmmtion seen. Fetures consistnt :nn,n""""t~1 Submitrl NM 1 19 F Hert JK MM NL TK KN 9 1 F I 12 F nd mteril nd, chronic non MB

20 19 ws it venous.( 1 seen. were no none 15 or 5 recurrence. re

21 20 occurs one were seen sme cuses s or

22 22 r or ure 1) or il gross With "... '"n'... ''''' John W Brlow /-'PI"c;nprr'IVI"C; on the Mitrl vlve Section 2 183

23 23 [1 ilure ] or revel or s c d c re common cuses in n *]. ex ue is re

24 With sc. "":"',,,,,,' John W Brlow I-'er'SDf'.!CClIVeS on the Mitrl vlve 6, Section N is is

25 25 present only if the neurysm is not of recent origin [14,1 *]. The lung fields my commonly demonstrte upper lobe diversion of pulmonry blood flow consistent with pulmonry venous congestion. (Figure 3) Postero-nterior (A) nd lterl (8) chest rdiogrph of 64 yer old womn, showing lrge multiloculted clcified submitrl neurysm. (Arrows) With permission: John W Brlow Perspectives on the Mitrl vlve Chpter 6, Section 2 Pge Electrocrdiogrphicl Fetures The ECG is norml in minority of cses, nd Chessler found only one completely norml ECG in 15 ptients with submitrl neurysms [2]. Electrocrdiogrphicl evidence of left ventriculr hypertrophy, out of proportion to the severity of the mitrl regurgittion, my suggest the possibility of n dditionl hemodynmic lod on the left ventricle [1 *]. Low voltges, nonspecific ST -segment nd T-wve chnges nd signs of myocrdil ischemi or infrction my be encountered. Electrocrdiogrphicl evidence of ischemi is often due to distortion or obstruction of the left circumflex coronry rtery long its course in the trioventriculr groove [4,9,13]. Ptients presenting with ventriculr tchycrdi hve lso been encountered [4]. Atril fibrilltion is lso common due to the left tril enlrgement [14J. Conduction disturbnces such s first-degree hert block re not uncommon nd my lso be relted to myocrdil ischemi produced by

26 on coron 26 rms c if it is is necess to ssess ure 4 or

27 A 27 B (Figure 4 A, B) (A) Angiogrm in the right nterior oblique position. (B) Angiogrm in the Left lterl position, both demonstrting LVSMA. (AO) Aort, (LV) Left ventricle, (AN) Aneurysm, (LA) Left trium, (T) Thorcic ort. The rrows in (B) demonstrtes the clcified rim of the LVSMA With permission: John W Brlow Perspectives on the Mitrl vlve Chpter 6, Section 2 Pge 183

28 28 4. Echocrdiogrphic Fetures 2-D echocrdiogrphy demonstrtes submitrl neurysm s n echofree spce rising below the posterior mitrl leflet extending posteromedilly nd superiorly to compress the left tril cvity. Communiction with the left ventriculr cvity cn then be seen in the region of the trioventriculr groove. The mitrl vlve pprtus is very well visulized nd mitrl incompetence cn redily be demonstrted. Mitrl incompetence is usully due to lck of leflet co-pttion nd distortion of the mitrl vlve. Becuse of crdic displcement nd vrible position of the neurysms, unconventionl views re sometimes necessry to demonstrte them. Left ventriculr (LV) contrst echocrdiogrphy cn lso be used [23]. A pigtil ctheter is plced in the LV nd the ptients blood is used s the contrst gent to determine mitrl regurgittion nd to locte the neck of n neurysm. A flil posterior leflet provides importnt ncillry evidence of the existence of submitrl neurysm, provided tht other cuses such s degenertive myxomtous disese, trum, infective endocrditis, nd cute rheumtic crditis hve been excluded. Fig 5 A

29 29 A B c Fig 5 B (Figure 5 A,B) 2-D echocrdiogrphy pictures demonstrting two different ptients with LVSMA. The LVSMA is seen s n echo-free spce rising below the posterior mitrl leflet extending postero-medilly nd superiorly to compress the left tril cvity. (Ao) Aort, (LA) Left trium, (MV) Mitrl vlve, (An) Aneurysm, (LV) Left ventricle, (N) Neck of neurysm, (AL) Anterior leflet on mitrl vlve, (PL) Posterior leflet of mitrl vlve

30 30 5. Computed Tomogrphy (CT) The use of CT nd contrst CT in defining the position, size, presence nd extent of thrombus nd clcifiction hs represented mjor dvnce in the dignosis nd ssessment of submitrl neurysms. Brlow reports tht CT ws positive in ll seven ptients in whom it ws performed, nd the informtion obtined equled or surpssed tht derived from ngiogrphy [1 *]. CT provides n excellent non-invsive method of investigtion in suspected cses of submitrl neurysm. A ---~---

31 31 B (Figure 6) A) Consecutive contrsted Computed tomogrphy (CT) scn in 31 yer old mle demonstrting the (A) neurysm nd its communiction, vi wide neck (N) with the left ventricle (LV) Extensive thrombus formtion is seen in the neurysm. (Figure 6) B) Single frme of CT scn sequence clerly demonstrting the LVSMA (AN) in reltion to the ort (AG), left ventricle (LV) nd the left trium (LA). With permission: John W Brlow Perspectives on the Mitrl vlve Chpter 6, Section 2 Pge

32 32 ~~~ is or n severe [ ], 1] his ws cuse ws n or smll if re is or

33 SDi:jCt::S re u d or is m r ilure.

34 sc is common. is two

35 35 From uences usu ( 8 Abrhms DG, Brton 0, Cockshot WP, Annulr Subvlvr left ventriculr neurysms Q J Medl : nn some s seen is if rms.

36 36 A (Figure 8 A) : Left Ventriculogrms in the right nterior oblique plne. LVSMA expnded nd involving the whole mitrl nnulus s found in two of the ptients in Group III. Contrst medium hs been injected into the left ventricle (LV) vi the ortic root (A). The contrst medi is seen filling the LV nd the left trium (LA) indicting severe mitrl incompetence. The LVSMA (AN) is outlined with the dshed line. Fig A: With Permission: H.J. Du Toit et l. Interctive Crdiovsculr nd Thorcic Surgery 2 (2003) Aneurysms tend to be lrge s shown in the intr-opertive photogrph becuse they trck in circulr direction. Enlrgement is lterlly, nteriorly nd superiorly by hernition through the ttchment of the left ventriculr muscle nd the fibrous vlve ring. They my be loculted nd in ll instnces contin clot, fresh nd lminted, s well s cellulr debris. Clcifiction of the lminted clot my develop (Figure 9)

37 37 (Figure 9): Intr-opertive photogrph of LVSMA, shown here s the whitish bulging structure to the left of the imge. The ortic cnnul (crnil) is seen in the centre bottom of the photogrph nd the diphrgm t the top (cudl) Arrows indicting LVSMA The left trium my be compressed nd the circumflex rtery my be gretly stretched nd nrrowed long its course in the trio-ventriculr groove by the neurysm. This my produce symptoms of ngin pectoris nd my led to myocrdil infrction due to coronry rtery occlusion or thrombosis. (Figure 10,11)

38 38 COn?.oress eel. c/rc ", x rtery' 1 (Figure 10) Digrmmtic representtion of stretching nd compression of the circumflex coronry rtery by the enlrging neurysm. A) Reflection of the pericrdium demonstrting the reltionship of the crdic structures. B) Sggitl view of the LVSMA. circumflex coronry rtery by the neurysm From: Clerkin lp, Bunje H Rre crdic neurysm in young dult Thorx 1955;10:42-45 C) Compression of the

39 39 (Figure 11) Angiogrm of the Left coronry system in the right nterior oblique plne. Stretching nd prtil occlusion of the circumflex rtery is demonstrted (lower right of picture) From : Clerkin JP, Bunje H Rre crdic neurysm in young dult Thorx 1955;10:42-45

40 n exc:es;slv'e or if cuse severe su i. re in n m u n [ is A

41 41 or n n MJ Antunes Submitrl Left Ventriculr J Thorcic Crdiovsc 1

42 43 (Figure 13) Intr-opertive photogrph of extr-crdic pproch. The forceps nd eyelid retrctor re in the neurysm cvity_ A ptch of utologous pericrdium is being sewn into plce

43 1 cses to s s or com nnu or one v

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