1
Assistant Professor, Department Of Cardiology, IGMC Shimla, India
2
Professor Department Of Cardiology, Igmc Shimla, India
3
Professor Department Of Cardiology, Igmc Shimla, India
Corresponding author details:
Shivani Rao, Assistant Professor
Department of Cardiology
shivanirao1109@gmail.com
IGMC Shimla,India
Copyright:
© 2020 Rao S, et al. This is an
open-access article distributed under the
terms of the Creative Commons Attribution
4.0 international License, which permits
unrestricted use, distribution, and
reproduction in any medium, provided the
original author and source are credited.
Submitral aneurysm is a rare entity with most cases described in the African population.
Sporadic case reports in the last two decades has documented their existence in the Indian
population. Ischemic origin of a Submitral aneurysm is extremely rare. Patients may present
with heart failure, thromboembolism, ventricular arrhythmias or sudden cardiac death. We
present a case of a submitral aneurysm presenting to us with ventricular tachycardia to the
emergency department.
Submitral Aneurysm; Ventricular Tachycardia
A 65-year-old male presented to the emergency department with hypotension and
hemodynamic collapse. His ECG showed monomorphic ventricular tachycardia right
axis with right bundle branch morphology (Figure 1). The precise location on ECG was
anterolateral mitral annular VT. It was DC cardioverted with 360J. He had an old history
of inferior wall myocardial infarction 3 years back. His baseline ECG showed QS pattern in
inferior leads (Figure 2). The patient had stopped his medications. His serum electrolytes and
troponin T were normal. Echocardiography revealed akinetic apical inferior, inferolateral,
and inferoseptal segments of the left ventricle. A 6 X 6 cm wide-necked aneurysm was seen
arising from the mid and basal inferior wall of LV at its junction with posterior mitral leaflet.
A large clot was noted in this aneurysm (Figure 3). The patient was planned for further
investigations but due to financial constraints, he requested for discharge. On discharge his
blood pressure was 100/70 mmHg with normal sinus rhythm [1].
Figure 1: ECG showing monomorphic ventricular tachycardia with right bundle branch
morphology, precise location anterolateral mitral annular VT
Figure 2: Post DC shock ECG showing QS pattern in inferior leads
Figure 3: Transthoracic Echocardiograph image showing wide
necked SMA with the presence of a large clot
In 1812 Corvisart first described Submitral Aneurysm (SMA) and since then, worldwide
only 100-120 cases have been reported [2]. Thus, SMA is a rare entity and most cases
have been described in an African population [3]. Its etiology is still a subject of debate
but it is mostly due to a congenital weakness of the fibrous annulus of the valve [4]. The
co-existence of this condition with Takayasu’s arteritis, tuberculosis pericarditis, following
mitral valve endocarditis or mitral valve replacement, and as a sequel to electrophysiology
studies has been reported [5]. Ischemic origin of SMA is extremely rare. SMA has varied
clinical manifestations like heart failure, systemic thromboembolism, ventricular wall rupture, ventricular arrhythmias or sometimes-sudden cardiac
death. According to the Coronary Artery Surgery Study, the incidence
of the left ventricular aneurysm in patients with acute myocardial
infarction was 7.6% and symptomatic intractable ventricular
arrhythmias were documented in approximately 15% of patients [6].
The usual sites of LVA are the anterior and apical segments (80%),
and rarely in the inferior wall (5–10%). SMAs may provide the
arrhythmogenic substrate for reentry circuit which can manifest in
RBBB or LBBB like morphology VT. Management strategies for VTs
are directed towards prevention of sudden death and recurrent lifethreatening arrhythmias by antiarrhythmic drug therapy, defibrillator implantation (if refractory to ablation) or aneurysmectomy [3].
Early recognition of this condition is important to prevent and
treat various complications that can arise due to SMA. This case
illustrates that SMA can present as VT to the emergency department
and it should be suspected when there are QS-waves in the ECG.
Copyright © 2020 Boffin Access Limited.