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(Circulation. 1999;100:211-214.)
© 1999 American Heart Association, Inc.

Correspondence

Submitral Aneurysm Is Not A False Aneurysm

Tsung O. Cheng, MD

Professor of Medicine Division of Cardiology, George Washington University, Washington, DC

	Introduction

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To the Editor:

I enjoyed reading the beautifully illustrated case report of submitral aneurysm by Kontozis et al.¹ However, I questioned the appropriateness of the term "false aneurysm" used by the authors to describe the submitral left ventricular aneurysm.

False aneurysm is a healed myocardial free-wall rupture of a myocardial infarct.² Because the authors stated clearly that submitral left ventricular aneurysms are caused by a congenital defect in the posterior portion of the mitral anulus, they are not true "false aneurysms."

Submitral left ventricular aneurysm is a peculiar form of left ventricular aneurysm, occurring almost exclusively in Negroid people and being noncoronary in etiology, that is, situated immediately beneath the posterior leaflet of the mitral valve.^{3 4}

Submitral left ventricular aneurysms have a variety of clinical presentations. Distortion of the mitral anulus produces mitral regurgitation.⁵ The larger submitral aneurysm may accommodate a large regurgitant volume during systole that is returned to the left ventricle in diastole, thus placing an additional hemodynamic burden on the left ventricle.⁴ Rupture of the aneurysm may cause cardiac tamponade or death.^{3 5}

In rare situations, submitral left ventricular aneurysm may, via several mechanisms, cause coronary artery obstruction.⁶ The latter, in turn, may result in acute myocardial infarct, which may rupture, thus possibly causing a false aneurysm of the left ventricle if the patient survives.

	References

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1. Kontozis L, Skoularigis J, Skudicky D, Sareli P. Submitral aneurysm. Circulation. 1998;98:1698.[Free Full Text]
   
2. Cheng TO. Perforated ventricular aneurysm in a male suffering from pneumonia. Clin Cardiol. 1992;15(3):A24, 223.
   
3. Antunes MJ, Sareli P, Pocock WA. Submitral left ventricular aneurysm. In: Barlow JB, ed. Perspectives on the Mitral Valve. Philadelphia, Pa: FA Davis; 1987:183–197.
   
4. Chesler E, Joffe N, Schamroth L, Meyers A. Annular subvalvular left ventricular aneurysms in the South African Bantu. Circulation. 1965;32:43–51.[Abstract/Free Full Text]
   
5. Chesler E, Tucker RBK, Barlow JB. Subvalvular and apical left ventricular aneurysms in the Bantu as a source of systemic emboli. Circulation. 1967;35:1156–1162.[Abstract/Free Full Text]
   
6. Cheng TO. Ventricular aneurysm and coronary artery disease: the hen and the egg? Cathet Cardiovasc Diagn. 1997;41:468.[Medline] [Order article via Infotrieve]
   

Response

Daniel Skudicky, MD; Pinhas Sareli, MD

Department of Cardiology, Baragwanath Hospital, Johannesburg, South Africa

	Introduction

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We appreciate the comments of Dr Cheng. The origin of submitral aneurysms is unknown. A congenital origin has been postulated,^{1 2} although an inflammatory origin has also been proposed. The congenital origin is supported by the fact that submitral aneurysms are almost exclusively observed in black African patients. Chesler et al² suggested that a defect in the muscular fibrous junction below the intermediate portion of the posterior mitral leaflet leads to a hematoma contained by the epicardium. Organization of this hematoma results in a fibrous walled epicardial aneurysm that may expand under the influence of the high pressure in the left ventricle. Thus, submitral aneurysms are essentially false aneurysms.³ These aneurysms can also be situated between the aorta and the heart, and in this case, a similar etiology has been postulated that results in the formation of a false aneurysm.⁴

	References

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1. Abrahams DG, Barton CJ, Cockshott WP, Edington GM, Weaver EJM. Annular subvalvular left ventricular aneurysms. Quart J Med. 1962;31:345–360.
   
2. Chesler E, Joffe N, Schamroth L, Meyers A. Annular subvalvular left ventricular aneurysms in the South African Bantu. Circulation. 1965;32:43–51.
   
3. Barlow JB, Antunes MJ, Sareli P, Pocock WA. Submitral left ventricular aneurysm. In: Perspectives on the Mitral Valve. Philadelphia, Pa: FA Davis Co; 1987:183–197.
   
4. Weldon CS. Surgical repair of a false aneurysm of the left ventricle resulting from a separation between the aorta and the heart. Circulation. 1967;35:954–961.[Abstract/Free Full Text]
   

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