Letter to the Editor Perforated aneurysm on the posterior leaflet of the mitral valve Aristides Androulakis * , Constadina Aggeli, Dimitrios Chrisos, Ioannis Kallikazaros, Pavlos Toutouzas Hippokration Hospital of Athens, University of Athens, Athens, Greece Received 16 June 2003; received in revised form 12 November 2003; accepted 17 November 2003 Available online 12 April 2004 Abstract We present a case of a 71-year-old homeless diabetic man who was hospitalized due to bilateral cellulitis of the lower limbs. Because of severe calcific aortic stenosis, he had undergone valve replacement by a bioprosthesis 3 years earlier. Except from the two preadmission days, he reported no fever, malaise, or weight loss at any time after surgery. On examination, no specific signs or symptoms suggesting infective endocarditis were noted. After six blood cultures were taken, the patient was put on cloxacillin, clindamycin and gentamicin. All the six blood cultures were finally proven to be negative. D 2004 Elsevier Ireland Ltd. All rights reserved. Keywords: Aneurysm; Mitral valve; Endocarditis A routine transthoracic echocardiogram was performed on the first hospital day. The left ventricle was not dilated, was hypertrophic and had preserved systolic function. The left atrium was mildly enlarged. The aortic bioprosthesis presented a 30-mmHg peak transvalvular pressure gradient and mild regurgitation, and findings were almost identical to those of the postoperative study, 3 years earlier. However, a vegetative mass was detected on the posterior leaflet of the mitral valve. Consequently, a transesophageal echocardio- gram was immediately performed. A markedly pulsating aneurysm on the posterior mitral valve leaflet was detected, with the cavity expanding in early systole (2.3 Â 2.8 cm) and collapsing in diastole (Fig. 1A and B). Furthermore, a perforation of the lesion into the left atrium was demon- strated (Fig. 2). An eccentric jet of moderate mitral valve regurgitation was also detected. No vegetations were found either on the aortic bioprosthesis or on the mitral valve. Mitral valve aneurysm formation is a rare complication in patients with aortic valve endocarditis, the most possible explanation being the development of satellite infection on the anterior mitral leaflet [1–3]. In the absence of endocarditis, stress alone due to a regurgitant aortic jet has been speculated to be the most possible cause of mitral aneurysm [4]. Our case seems to be a very rare incident since the aneurysm was detected on the posterior mitral valve leaflet, where any mechanical stress due to aortic regurgitation could be profound- ly less compared to that acting on the anterior one. Furthermore, in our patient the aortic prosthesis was only mildly regurgitant whereas endocarditis was never documented. The patient received the aforementioned treatment for 10 days and had an uneventful recovery. He denied any further cardiac studies and was discharged with the advice for a regular follow-up. References [1] Reid CL, Chandraratna PAN, Harrison E, et al. Mitral valve aneurysm: clinical features, echocardiographic – pathologic correlations. J Am Coll Cardiol 1983;2:460 – 4. [2] Karalis DG, Bansal RC, Hauck AJ, et al. Transesophageal echocardio- graphic recognition of subaortic complications in aortic valve endocar- ditis: clinical and surgical implications. Circulation 1992;86:353 – 62. [3] Chan KL. Mitral valve aneurysm in endocarditis. Circulation 2000; 102(13):E102. [4] Cai TH, Moody Jr JM, Sako EY. Mitral valve aneurysm due to severe aortic valve regurgitation. Circulation 1999;100:e53 – 6. 0167-5273/$ - see front matter D 2004 Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.ijcard.2003.11.018 * Corresponding author. 30 Dodekanisou Street, Vrilissia, 152 35 Athens, Greece. Tel.: +30-210-8047-172; fax: +30-210-8041-350. E-mail address: antaris@otenet.gr (A. Androulakis). www.elsevier.com/locate/ijcard International Journal of Cardiology 98 (2005) 163 – 164