Membranous Ventricular Septal Aneurysm
Patient presentation:
An 86 year old female with a history of hypercholesterol- emia, hypertension and peripheral vascular disease developed dizziness, dyspnea and mild chest pain. She was brought to the emergency department of an outlying hospital and was diagnosed with supraventricular tachycardia. After receiving intravenous diltiazem, she converted to normal sinus rhythm and had no further dyspnea or chest pain. She was admitted to the hospital for observation and cardiac enzymes were noted to be elevated (troponin I=5.4). She was transferred to hospital for cardiac catheterization. Clinical course...
Membranous Ventricular Septal Aneurysm
Physical examination:
The patient appeared comfortable
HR=60, BP=128/70, afebrile, RR=16
Neck: no jugular venous distention or bruit
Lungs: clear
Heart: normal rate, regular rhythm, 2/6 systolic ejection murmur
Hospital Course: The patient underwent cardiac catheterization. Angiography revealed a 30% left main lesion, 40% proximal left anterior descending lesion and 50% mid right coronary artery stenosis. The LVEF was estimated at 80% and 2+ mitral regurgitation was noted. The LVEDP was 10 and there was no gradient across the aortic valve and only a minimal intracavitary gradient. Localized aneurysmal tissue below the aortic valve was noted without VSD or aortic regurgitation.
Aneurysms of the membranous septum without residual shunt may represent the natural history of spontaneously closing VSD's of childhood. Generally spontaneous closure of membranous VSD's, if it occurs, will be complete by age 10 and frequently leaves no residual deformity. Discovery of these silent aneurysms may be incidental to routine echocardiography. Antibiotic prophylaxis is not recommended.
Ventricular angiogram shows the membranous aneurysm as a pocket of contrast just below the aortic valve. There is no septal defect or communication and no aortic regurgitation. Mitral regurgitation however is noted.
The apical 5 chamber view shows the out-pouching of the membranous septal aneurysm into the RVOT.