Radiology_May04


REVIEW ARTICLE

50 SA JOURNAL OF RADIOLOGY • May 2004

A 74-year-old man with a produc-
tive cough was referred from a periph-
eral hospital. The referral diagnosis
queried a calcified echinococcus cyst
in the left hemithorax.

Chest X-ray
Figs 1 and 2 show PA and lateral

views. What are the relevant findings?
The patient was then referred for an
echocardiogram (Figs 3 and 4) and
MRI study (Figs 5 - 8). What is your
diagnosis?

The big-hearted man
now in trouble

Irma van de Werke
FRCR

Zarina Lockhat
FFRad(D)SA

Betsie van der Walt
FCRad(D)SA

Rowaida Abdullah
MB ChB

Department of Radiology
University of Pretoria  

Fig. 1.  

Fig. 2.  

Fig. 3.  

Fig. 4.  

Fig. 5.  

Fig. 6.  

Fig. 7.  

Fig. 8.  



51 SA JOURNAL OF RADIOLOGY • May 2004

QUIZ CASE

Discussion
PA and lateral chest X-rays demon-

strate cardiomegaly with an oval-
shaped mass with rim calcification in
the region of the left atrium and ven-
tricle.

Echocardiogram
A large aneurysm is noted in the

region of the left ventricle, at the sub-
mitral valve level.

MRI
The four chamber view shows a

large aneurysm in the postero-lateral
wall of the left ventricle. It is situated
just inferior to the posterior mitral
valve cusp. Rim calcification is pre-
sent. On the two chamber view the
aneurysm is again noted in the left
ventricular region.

Discussion
Mitral subannular left ventricular

aneurysms are not seen frequently.
Those described have occurred most-
ly in Africa and India.4

These aneurysms arise in the
fibrous ring below the mitral or aortic
valve. The submitral type is more
common than the subaortic type.
Submitral aneurysms occur in the
epicardium, related to the base of the
left ventricle.5

These aneurysms have ovoid ostia
which are frequently multiple and
located under the posterior leaflet of
the mitral valve.

The aetiology is unknown though
a congenital defect in the posterior
mitral valve annulus has been postu-
lated.

These aneurysms are false and may
reach enormous proportions. They
may calcify or contain mural throm-

bus. Complications include myocar-
dial ischaemia and infarction, sys-
temic embolisation, congestive car-
diac failure and infective endocarditis
as well as rupture of the aneurysm.
Surgical resection of the aneurysm
with or without valve replacement is
indicated in severe valvular regurgita-
tion or cardiac failure resistant to
medical therapy.

The acquired causes may be due to
infection, myocardial infarction, colla-
gen vascular disease, Takayasu's arteri-
tis, myocarditis or trauma.

Addendum
We refer to the publication of our

first case in the South African Journal
of Radiology of March 2002.6 The sub-
sequent case demonstrates  the differ-
ent plain chest film and ultrasound
appearances of the subannular left
ventricular aneurysms (Figs 9 - 12).

Acknowledgement
We would like to thank Annelize

Gates for her assistance in preparation
of this article.

Fig. 10.  

Fig. 11.  

Fig. 12.  

Fig. 9.  



REVIEW ARTICLE

52 SA JOURNAL OF RADIOLOGY • May 2004

References
1. Edelstein CL, Blake RS, Klopper JF. Mitral sub-

annular left ventricular aneurysm. S Afr Med J
1987; 71: 114 - 115.

2. Chesler E, Joffe N, Schamroth C, Meyers A.
Annular subvalvular left ventricular aneurysms
in the South African Bantu. Circulation 1965;
XXXII: 43 - 51.

3. Edington GM, Williams AO. Left atrial
aneurysms associated with annular subvalvular
left ventricular aneurysms. Journal of Pathology
and Bacteriology 1968; 96: 273 -283.

4. Taneja K, Mathur A, Sharma S, Rajani M, Das B,
Venugopal P. Magnetic resonance imaging fea-
tures of submitral left ventricular aneurysm.
Indian Heart J 1998; 50: 453 - 455.

5. Chesler E. Aneurysms of the left ventricle.
Cardiovascular Clinics 1972; 4: 187 - 217.

6. Van de Werke I, Lockhat Z, Van der Walt E,
Abdulla R. Calcified mitral subannular left ven-
tricular aneurysm. South African Journal of
Radiology 2000; 6: 33 - 35.

Erratum
In the case report entitled ‘Recurrent life-threatening haemoptysis in pulmonary tuberculosis — the importance of pul-
monary angiography’ from the November 2003 SAJR, vol 7 no 4, page 23, the third author (R Naidoo, Department of
Thoracic Surgery, Wentworth Hospital) was unfortunately omitted in error. The authors should be: S Msimang, P Corr,
R Naidoo.