Quick Fire Cases
SUMAN SINGHAL, MD
DIRECTOR CARDIAC IMAGING, HEAD OF DEPARTMENT
MAHAJAN IMAGING ,FORTIS ESCORTS HOSPITAL JAIPUR, India
SUMAN SINGHAL, MD
DIRECTOR CARDIAC IMAGING, HEAD OF DEPARTMENT
MAHAJAN IMAGING ,FORTIS ESCORTS HOSPITAL JAIPUR, India
RAHUL SINGHAL, MD
ADDITIONAL DIRECTOR CARDIOLOGY AND CARDIAC ELECTROPHYSIOLOGY
FORTIS ESCORTS HOSPITAL JAIPUR, India
A 40-year-old male, hypertensive, non-diabetic, smoker came with complaints of chest discomfort and fatigue since last one month. On clinical examination vitals were normal. ECG showed left bundle branch block. Chest X-ray was normal. On echocardiography, a well-defined cystic lesion was seen in interventricular septum. No regional wall motion abnormality, no systolic anterior motion, no intra-cavitary gradient was present, Grade I left ventricle (LV) diastolic dysfunction with normal ejection fraction.Patient was advised Cardiac magnetic resonance imaging (CMR) for further characterization of the cystic lesion ? Abscess? sinus of Valsalva aneurysm. On CMR, well -defined, bilobed cystic lesion was seen in basal interventricular septum with a thin septation/flap between the two lobes of the lesion. On dynamic contrast perfusion images there was intense contrast filling within the cystic lesion same as in LV with a thin communication from anteroinferior aspect of left ventricular outflow tract (LVOT) just below right aortic cusp. Final diagnosis of interventricular septal aneurysm was given excluding close differential of dissecting aneurysm of sinus of Valsalva (SOV).
Diagnostic Techniques and Their Most Important Findings:
Echocardiography revealed well defined anechoic cystic lesion in interventricular septum with color flow and pulsations (Figure 1).
On CMR (3.0 Tesla scanner) a well -defined, bilobed cystic lesion was seen in basal interventricular septum with dimensions of 18 x 33 x 17mm. The lesion increased in size during systole with thin intralesional septation/flap on cine SSFP sequences (Figure2). Cystic lesion was of heterogeneous signal intensity similar to blood on all sequences with no fat/thrombus. On dynamic contrast perfusion sequence, there was intense contrast filling within the cystic lesion same as in LV with a thin (3-4mm) subaortic communication in membranous interventricular septum just below normal right SOV (Figure 3). Mild delayed contrast enhancement was seen within the lesion. No shunt was seen with normal Qp/Qs ratio. Final diagnosis of interventricular septal (IVS) aneurysm was made.
Learning Points from this Case:
Interventricular septal (IVS) aneurysm is a rare condition usually seen as an incidental finding on echocardiography and can be mistaken for a dissecting aneurysm of right sinus of Valsalva.
Differentiating interventricular septal aneurysm from an aneurysm of the right sinus of Valsalva is crucial as the latter usually has a more aggressive course and may require surgical intervention. Non invasive multimodality imaging with Cardiac computed tomography (CT) or CMR play a crucial role to reach an accurate diagnosis for appropriate management .
Aneurysm of the sinus Valsalva shows saccular dilatation of the aortic sinus while IVS aneurysm lies immediately subaortic with normal aortic cusp . In dissecting aneurysm of right SOV, the cystic mass-like aneurysm increases during diastole with flow communicating from the aortic root to the interventricular aneurysm, due to the higher pressure in the aorta compared to left ventricular diastolic pressure. Conversely, IVS aneurysm increases during systole with flow communicating from the left ventricle to the IVS dissection, because in systole, the pressure in the left ventricle is higher as in our case.
IVS aneurysm usually has a benign course and does not require surgical intervention unless it is associated with complications of thromboembolism or threatening ventricular arrythmias. Large aneurysms may cause right ventricular outflow tract obstruction.
