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Images in cardiovascular medicine
Submitral aneurysm: a rare cause of ventricular tachycardia
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  1. Pradeep Kumar,
  2. Jayaraman Balachander,
  3. Raja J Selvaraj
  1. Department of Cardiology, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, India
  1. Correspondence to Dr Raja Selvaraj, Department of Cardiology, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry 605006, India; rajajs{at}gmail.com

http://dx.doi.org/10.1136/heartasia-2012-010149

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    A 42-year-old male presented with sustained ventricular tachycardia of left bundle branch block (LBBB) morphology with left axis deviation (figure 1A) that terminated with amiodarone infusion. He gave a history of episodic palpitations associated with giddiness. Transthoracic and transoesophageal echocardiography showed a wide necked submitral aneurysm measuring 5×5 cm with severe mitral regurgitation (figure 1B,C).

    Figure 1
    Figure 1

    ECG at presentation and transoesophageal echocardiography (TEE). ECG at presentation showing ventricular tachycardia of left bundle branch block morphology (A). TEE shows the large aneurysm beneath the posterior mitral leaflet (B). Colour Doppler demonstrates severe mitral regurgitation (C). LA, left atrium; LV, left ventricle; MV, mitral valve; LAA, left atrial appendage.

    Coronary angiogram revealed a dominant right coronary artery with spontaneous dissection of mid and distal segments with splaying of the distal branches overlying the aneurysm (figure 2A,B). Ventricular tachycardia of right and left bundle branch block morphologies was induced with single ventricular extrastimuli during electrophysiological testing. MRI clearly demonstrated the aneurysm below the mitral valve (figure 2C,D). The patient was prescribed oral amiodarone and advised surgical resection of submitral aneurysm with mitral valve repair or replacement.1

    Figure 2
    Figure 2

    Coronary angiogram and MRI images. Coronary angiogram shows normal left coronary artery in right anterior oblique view (A) and left anterior oblique view of right coronary artery suggestive of spontaneous dissection (B). MRI shows the wide necked diverticulum (C, D). LA, left atrium; LV, left ventricle; SMA, SubMitral Aneurysm.

    Discussion

    Submitral aneurysm is rare outside African blacks and uncommonly presents with ventricular arrhythmias.2 While the aetiology is considered to be congenital, coronary abnormalities have occasionally been described in association with this condition, although the relationship of the coronary abnormality to the aneurysm is unclear in our patient.

    References

    1. ↵
      1. Du Toit HJ,
      2. Von Oppell UO,
      3. Hewitson J,
      4. et al
      . Left ventricular sub-valvar mitral aneurysms. Interact Cardiovasc Thorac Surg 2003;2:547–51.
      OpenUrlAbstract/FREE Full Text
    2. ↵
      1. Kazemi B,
      2. Arya A,
      3. Haghjoo M,
      4. et al
      . Idiopathic submitral left ventricular aneurysm: an unusual substrate for ventricular tachycardia in caucasians. Indian Pacing Electrophysiol J 2005;5:244–9.
      OpenUrlPubMed

    Footnotes

    • Contributors PK contributed to management of the patient and preparation of the manuscript. JB oversaw the management of the patient. RJS was involved in management of the patient and preparation of the manuscript. JB and RJS accept full responsibility and will act as guarantors for the completed paper.

    • Competing interests None.

    • Patient consent Obtained.

    • Provenance and peer review Not commissioned; internally peer reviewed.