{"paper_id":"1b03a447-3e6f-4646-be5e-2dcc34bde379","body_text":"Thirty-three years follow-up of pseudoaneurysm of the mitral-aortic intervalvular fibrosa without surgical treatment: case report and literature review | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Case Report Thirty-three years follow-up of pseudoaneurysm of the mitral-aortic intervalvular fibrosa without surgical treatment: case report and literature review Seyed Mohsen Mirhosseini, Mahdi Rezaei, Hossein Yarmohammadi, and 3 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-3964434/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 20 Jun, 2024 Read the published version in Journal of Cardiothoracic Surgery → Version 1 posted 20 You are reading this latest preprint version Abstract Background The pseudoaneurysm of the mitral-aortic intervalvular fibrosa (PMAIF) is a rare complication of endocarditis or aortic valve surgery. Surgical treatment is often suggested, but the possibility of conservative management remains unclear. Case presentation The 33-year follow-up of a PMAIF that developed six years after aortic valve replacement (AVR) is reported. Initially, the patient began experiencing worsening dyspnea, and echocardiography revealed an ejection fraction (EF) of 20% with a PMAIF measuring 7 × 10 mm. Despite being advised to undergo surgery, the patient declined due to fear of high-risk surgical outcomes. Consequently, conservative treatment with close observation but without surgery was initiated. During the 33-year follow-up period, the patient did not exhibit any adverse health effects. Conclusion The surgery is not necessary for asymptomatic patients with PMAIF, even in cases of sizable pseudoaneurysms, as long as there are no additional local complications or rapid growth. The conservative and non-surgical approach is particularly applicable to patients with a high risk for surgery, for whom regular clinical and echocardiographic monitoring appears to be safe for handling this condition. Pseudoaneurysm of the mitral-aortic intervalvular fibrosa PMAIF Heart surgery non-surgical treatment Case report Figures Figure 1 Figure 2 Introduction The disease known as pseudoaneurysm of the mitral-aortic intervalvular fibrosa (PMAIF) is a rare occurrence ( 1 , 2 ). The PMAIF is identified as a delicate and fibrous membranous that is situated between the aortic valve root and the mitral valve ( 3 ). This area serves as the connection point between the noncoronary cusp of the aortic valve and the anterior mitral leaflet which communicates with the left ventricular outflow tract ( 2 ). The PMAIF is commonly found in individuals with aortic valve infective endocarditis or undergoing aortic valve replacement (AVR) ( 4 , 5 , 6 ). The prognostication of PMAIF's clinical and surgical outcomes is challenging. It can be asymptomatic and uncomplicated or associated with complications such as rupture, embolization, and compression of vital ( 7 ). The occurrence of PMAIF rupture into the pericardium can be life-threatening ( 8 ). Therefore, when a PMAIF is identified, surgical intervention is commonly advised to all patients, regardless of their lack of symptoms ( 7 , 8 ). The surgical repair of PMAIF commonly involves aortic valve replacement or aortic root surgery and the presence of comorbidities can be contraindications for this surgery ( 8 ). Alternatively, a conservative therapeutic approach may be considered ( 7 ). Therefore, for these patients, close clinical observations and echocardiographic evaluations are necessary. The utilization of both transthoracic echocardiography (TTE) and transesophageal echocardiography (TEE) is recommended for all follow-up evaluations ( 8 , 9 ). This case report aims to gather limited evidence on experiences with PMAIF non-surgical management. This study describes a 33-year follow-up of a PMAIF in a patient with a prosthetic metallic aortic valve without experiencing any adverse clinical occurrences during follow-up. Case presentation The case describes a man who was born in the year 1960 and received a prosthetic metallic aortic valve due to severe aortic stenosis at the age of 25. He had no other significant past medical history except cranial surgery due to extradural hematoma after a trauma in 1984 which had no damage to his chest. He has been treated with warfarin 5 mg daily ever since with an International normalized ratio (INR) of 2.5. Also, echocardiography was performed annually and ejection fraction (EF) was around 50% through those years of follow-up. After six years following AVR, he started complaining of worsening dyspnea. He was referred to our center for the first time and in the work-up the echocardiography showed an EF of 20% with PMAIF with the size of 7 × 10 mm. During the consultation with cardiac surgery, he was informed that he needed to repair the pseudoaneurysm, however, he eventually refused to receive the surgery since he was afraid of high-risk procedure outcomes. Therefore, conservative treatment with close observation was initiated for him. The medical treatment for heart failure included losartan 25 mg daily, carvedilol 6.25 mg bd, furosemide 40 mg daily, and spironolactone 25 mg daily. Every three to six months blood profiles including INR were checked. Additionally, every six to 12 months his echocardiography was followed. In some instances, TEE was performed to determine PMAIF changes better. He has been followed up for 33 years and interestingly his prosthetic valve remained functional. Regular follow-up TTE which is presented in Table 1 , shows a minimal increase in the size of PMAIF with a stable EF in the range of 25–30% during the recent years. Figure 1 displays a TTE image of the patient. Also, the color Doppler echocardiography demonstrates the flow going to and fro in the PMAIF during systole and diastole (flow direction is marked by an arrow) shown in Supplementary File 1. Furthermore, a contrast-enhanced computed tomography scan demonstrates the characteristic appearance of a PMAIF, as shown in Fig. 2 . Finally, He had no complications such as a cerebrovascular accident. He is still working as a salesman and is satisfied with his quality of life since his symptoms such as dyspnea have improved significantly. Table 1 Echocardiography characteristics through 33 years of follow-up Date Echocardiography LVEF PMAIF Size Function of mechanical aortic valve Valvular disease PAP 7/24/1991 TTE 20% 7 × 10 mm N/A N/A N/A 10/05/2014 TEE 25–30% Communication with LVOT PPG: 44 mmHg MPG: 27 mmHg Mild MR 25 mmHg 09/07/2015 TTE 25% N/A PPG:36 mmHg MPG: 17 mmHg MR TR N/A 09/15/2016 TTE 30–35% N/A N/A MR N/A 06/13/2017 TTE 35% N/A PPG: 45 mmHg MPG: 26 mmHg MR N/A 07/22/2018 TTE 20–25% N/A PPG: 40 mmHg MPG: 20 mmHg Mild MR Mild TR Normal 05/09/2019 3D TDI 20–25% 9 × 13 mm No leakage N/A Mild MR N/A 06/27/2020 3D TEE + TTE 30–35% 11.3 × 15.9 mm Mild leakage N/A N/A N/A 06/16/2021 TDI 25–30% 13 × 18 mm No connection PPG: 36 mmHg MPG: 22 mmHg Mild MR Normal 07/14/2022 TDI 30% 16 × 20 mm Connection to LVOT (diameter 3 mm) PPG: 32 mmHg MPG: 19 mmHg Mild MR Mild to moderate TR 25 mmHg 04/17/2023 TDI 30% 15 × 17 mm Orifice 4.5 mm PPG: 30 mmHg MPG: 17 mmHg Mild MR Mild TR 30 mmHg TEE : Transoesophageal echocardiography, TTE : Transthoracic echocardiogram, mm : Millimetre, N/A : Not available, PAP : pulmonary artery pressure, MR : Mitral regurgitation, TR : Tricuspid regurgitation, PPG : peak pressure gradient, MPG : mean pressure gradient, LVOT : Left ventricular outflow tract, LVEF : Left ventricular ejection fraction, TDI : Tissue Doppler imaging Patient Perspective “ After being diagnosed with a PMAIF, I faced a critical decision regarding whether to proceed with corrective surgery or continue with non-surgical treatments. Having weighed the pros and cons carefully, and considering both options thoroughly, I ultimately chose the conservative based on several factors. As a salesman, I take pride in staying active and managing my condition responsibly. Thanks to proper medications, consistent care, and effective communication with healthcare providers, I can lead an ordinary life despite the challenges posed by my heart condition. It brings me great joy knowing that my symptoms, particularly shortness of breath, have considerably improved over time, contributing positively to my overall well-being and happiness. I managed to preserve an acceptable standard of living, performing my job duties efficiently and enjoying leisure activities without undue restrictions. ” Discussion and literature review A PMAIF is a recognized issue associated with both infective endocarditis of the aortic valve and artificial aortic valve implantation (10). While larger instances of PMAIF might be identified through TTE (8), the diagnosis of a PMAIF typically necessitates TEE (11). There have been recent advancements in the diagnostic methods for PMAIF, such as three-dimensional echocardiography, cardiac CT-scan, and MRI. However, it remains unclear what additional value these techniques offer compared to the standard two-dimensional TEE (12). The occurrence of complications may arise occasionally, but it is also possible for PMAIF to persist without complications or symptoms for indeterminate periods. These include the rupture into the left atrium or aorta, localized compression of a coronary artery causing myocardial ischemia, distortion of the mitral valve leading to mitral regurgitation, and the development of blood clots and subsequent distal embolization (13). Operative correction is frequently advised for managing PMAIF, yet the optimal therapy remains uncertain. In particular, the indication and timing of the surgical procedure continue to be a matter of debate. In many cases that have been recorded before, the recognition of a PMAIF required carrying out a surgical operation. Surgical procedures tend to be complicated and high-risk, often involving aortic valve replacement (often repeated valve replacement), repair of the aortic root, and restoration of the mitral-aortic intervalvular fibrosa (11). Reports of conservative management of PMAIF without surgical intervention are limited. However, there are instances in earlier studies where patients with PMAIF refused surgery and remained asymptomatic and in good health throughout follow-up periods. These cases generally showed favorable outcomes without experiencing adverse effects (14). The literature review includes 13 articles that report non-surgical methods for managing PMAIF, which are shown in Table 2. These studies cover a total of 25 patients from the years 2008 to 2022 and can be found in supplementary file 2. A significant portion of the patients were male, accounting for 17 out of the 25 cases documented. The age range of patients is quite broad, from 1 month up to 87 years old, indicating the diverse age groups needing cardiac diagnostics and interventions. Of all the patients, 9 men underwent some form of surgery. These surgeries include aortic valve replacement, mechanical valve implant, coronary artery bypass grafting, aortic valvotomy, resection for subaortic stenosis, and the Bentall procedure. In addition, 5 surgeries are reported for female patients, which include ventricular septal defect repair, aortic valve replacement, and composite graft replacement of the ascending aorta. Endocarditis was absent in most cases. However, three patients had past histories of endocarditis before their latest evaluations: two males aged 55 and 77 years old, and one female aged 87 years old (7, 8, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25). Table 2. Demographic, clinical characteristics and follow-up of patients with PMAIF in published articles First author (year) Characteristics (Number of Cases / Age / Sex) Prior surgery / Endocarditis Symptoms / Diagnosis Size (mm) Follow-up (year/size changes/complications) Bishara et al. (2022) (16) One 16 y male None None None TTE and TEE N/A 3 years Minor Changes None Niwano et al. (2021) (22) One 76 y female AVR None None TTE, TEE, MRI, and CT-Scan N/A 30 years Minor Changes Behçet’s disease Del Pasqua et al. (2018) (18) One 1 month female None None Innocent murmur TTE, TEE, and CT-Scan 7 × 6 mm 5 years 12 × 10 mm (Max Diameter) None Caro-Dominguez et al. (2017) (17) One 13 y male None None Chest Pain TTE and MRI N/A 6 months Minor Changes None Low et al. (2017) (21) Five ranged from 18 to 64 y five males Mechanical valve: One case None Arrhythmia: two cases TEE: Four cases TTE, MRI, and CT: Five cases Ranged from 16 to 52 mm (Mean:29 ± 13 mm) 4 years Minor Changes None Apostolidou et al., (2017) (15) One 84 y Male CABG None Dyspnea TEE N/A 15 months N/A None Han et al . (2016) (20) One 27 y Male None None None TTE 8 × 12 mm 3 years Minor Changes None Maria Bonou et al . (2015) (25) Two 42 y and 77 y one male and one female AVR: Two cases, CABG: one case Endocarditis: One case DOE and Palpitations: One case, Fever: One case TTE: One case TEE and CT: Tow cases 33 mm 22 mm 3-4 years Minor Changes None Şahan et al. (2014) (8) Three ranged from 23 to 71 y one male and two female None None None TTE and TEE: All cases 21 × 11 mm 12 × 31 mm 27 × 21 mm 3 years 49 × 78 mm in the second case, minor changes in others Takayasu in one case Hasin et al. (2011) (7) Two 43 y and 55 y Two male AVR: One case, Aortic valvotomy: One case One case endocarditis None TTE: One case TEE: Two Cases 40 mm 60 mm 5-16 years 48 mm and 68 mm in order None Gin et al. (2011) (19) Three ranged from 31 to 87 y one male and two female AVR: One case, VSD Repair and Resection SAoS: one case Endocarditis: One case None TEE: All cases 53 × 23 mm 76 × 49 mm 48 × 25 mm 3-9 years Minor Changes Rheumatic heart disease: One case Grimaldi et al. (2011) (24) Three Age range: 50 to 75 y Two male and one female AVR and Bentall procedure for severe AI: One case, AVR +CGR: One case None None TTE and TEE: All cases CT-Scan: One case 15 × 20 mm 15 × 20 mm 40 × 50 mm 4 years Minor Changes None Salerno et al. (2007) (23) One 82 y male Implantation of a biological aortic prosthesis None Fever TTE 62 mm 1 year Minor Changes None y : years, TEE : Transesophageal echocardiography, TTE : Transthoracic echocardiogram, AVR : Aortic valve replacement, CABG : Coronary artery bypass graft, VSD : Ventricular septal defect, CGR : Composite graft replacement, mm : Millimeter, SAoS: Subaortic stenosis, MRI : Magnetic resonance imaging, CT-Scan : Compound tomography scan, N/A : Not available Imaging and diagnostic tools included TTE for 19 patients, TEE for 21 patients, and MRI and CT scans for 11 patients. These tools were frequently used and mostly showed minor changes in aortic size over the follow-up periods, ranging from 6 months to 30 years. Regarding cardiac complications, most patients did not show any post-procedure complications. However, there was one case of Bechet’s disease, one case of Takayasu, and another with rheumatic heart disease. Furthermore, patients presented with a range of symptoms, including arrhythmias, fever, chest pain, and innocent murmurs. Ten patients presented with moderate and severe aortic regurgitation (AR), while moderate and severe mitral regurgitation (MR) appeared in four cases. Overall, four patients showed signs of both MR and AR (7, 8, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25). We suggest that more studies and long-term follow-ups of patients with PMAIF who have received non-surgical treatment should be conducted to prove the superiority of the non-surgical method over surgery. Our study was limited by incomplete and/or missing patient records. Additionally, our review was restricted to English literature related to this rare disease entity. Conclusion Based on our experience with these cases, we propose that surgery is not imperative for asymptomatic patients with PMAIF, even in cases of sizable pseudoaneurysms, as long as there are no further local clinical adverse effects or rapid growth. This conservative methodology is particularly applicable to individuals with a high risk for surgery, for whom regular clinical and echocardiographic monitoring appears to be safe. Abbreviations PMAIF Pseudoaneurysm of the Mitral-Aortic Intervalvular Fibrosa AVR Aortic Valve Replacement TTE Transthoracic Echocardiography TEE Transesophageal Echocardiography EF Ejection Fraction AR Aortic Regurgitation MR Mitral Regurgitation INR International normalized ratio CT-Scan Computed tomography scan mm millimeter mg milligram Declarations Standards of Reporting A CARE checklist has been provided in Supplementary File 3 for reporting case report studies. Ethics approval and consent to participate The patient permitted us to use clinical information and photographs to be published. Consent for publication Signed written informed consent was obtained from the patient. Availability of data and material Data are available based on a request from the corresponding author. Competing interests The authors confirm that there are no known conflicts of interest associated with this publication. Funding There has been no significant financial support for this work. Authors' contributions S.M.M. and F.B. contributed to conceptualizing the study and finalized the manuscript. M.S. and M.R. gathered data and contributed to writing the initial draft. H.Y. and E.F contributed to the visualization of figures performed the literature search and wrote the draft of the search result. Acknowledgments We would like to acknowledge Dr. Taraneh Faghihi Langroudi, M.D., for her review and confirmation of the computed tomography figure. 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Supplementary Files SupplementaryFile1.mp4 Supplementary File 1 .mp4 Color Doppler view of the PMAIF (arrow) SupplementaryFile2.xlsx Supplementary File 2 .xls Characteristics of 25 patients with PMAIF in published articles SupplementaryFile3.pdf Supplementary File 3 .pdf CARE checklist Cite Share Download PDF Status: Published Journal Publication published 20 Jun, 2024 Read the published version in Journal of Cardiothoracic Surgery → Version 1 posted Editorial decision: Revision requested 27 Apr, 2024 Reviews received at journal 12 Mar, 2024 Reviews received at journal 10 Mar, 2024 Reviews received at journal 07 Mar, 2024 Reviews received at journal 05 Mar, 2024 Reviews received at journal 03 Mar, 2024 Reviewers agreed at journal 03 Mar, 2024 Reviewers agreed at journal 02 Mar, 2024 Reviews received at journal 02 Mar, 2024 Reviewers agreed at journal 02 Mar, 2024 Reviews received at journal 01 Mar, 2024 Reviewers agreed at journal 01 Mar, 2024 Reviewers agreed at journal 01 Mar, 2024 Reviewers agreed at journal 01 Mar, 2024 Reviewers agreed at journal 01 Mar, 2024 Reviewers agreed at journal 01 Mar, 2024 Reviewers invited by journal 01 Mar, 2024 Editor assigned by journal 18 Feb, 2024 Submission checks completed at journal 18 Feb, 2024 First submitted to journal 17 Feb, 2024 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {\"props\":{\"pageProps\":{\"initialData\":{\"identity\":\"rs-3964434\",\"acceptedTermsAndConditions\":true,\"allowDirectSubmit\":false,\"archivedVersions\":[],\"articleType\":\"Case Report\",\"associatedPublications\":[],\"authors\":[{\"id\":273596278,\"identity\":\"e22dc429-bee9-47f8-94fd-61cbf14ac9b1\",\"order_by\":0,\"name\":\"Seyed Mohsen Mirhosseini\",\"email\":\"\",\"orcid\":\"\",\"institution\":\"Shahid Beheshti University of Medical Sciences\",\"correspondingAuthor\":false,\"prefix\":\"\",\"firstName\":\"Seyed\",\"middleName\":\"Mohsen\",\"lastName\":\"Mirhosseini\",\"suffix\":\"\"},{\"id\":273596279,\"identity\":\"350a8446-5b8a-47c6-bb0d-fd994fa56b7b\",\"order_by\":1,\"name\":\"Mahdi Rezaei\",\"email\":\"\",\"orcid\":\"\",\"institution\":\"Shahid Beheshti University of Medical Sciences\",\"correspondingAuthor\":false,\"prefix\":\"\",\"firstName\":\"Mahdi\",\"middleName\":\"\",\"lastName\":\"Rezaei\",\"suffix\":\"\"},{\"id\":273596280,\"identity\":\"1d240fad-80c0-4a46-a928-04d41212be66\",\"order_by\":2,\"name\":\"Hossein Yarmohammadi\",\"email\":\"\",\"orcid\":\"\",\"institution\":\"Shahid Beheshti University of Medical Sciences\",\"correspondingAuthor\":false,\"prefix\":\"\",\"firstName\":\"Hossein\",\"middleName\":\"\",\"lastName\":\"Yarmohammadi\",\"suffix\":\"\"},{\"id\":273596281,\"identity\":\"e809602a-07ba-48e1-bc04-86d00a0f0d5b\",\"order_by\":3,\"name\":\"Masood Soltanipur\",\"email\":\"\",\"orcid\":\"\",\"institution\":\"Shahid Beheshti University of Medical Sciences\",\"correspondingAuthor\":false,\"prefix\":\"\",\"firstName\":\"Masood\",\"middleName\":\"\",\"lastName\":\"Soltanipur\",\"suffix\":\"\"},{\"id\":273596282,\"identity\":\"eb2133d4-687c-4571-a8db-2885a2a77be4\",\"order_by\":4,\"name\":\"Eisa Fattah\",\"email\":\"\",\"orcid\":\"\",\"institution\":\"Shahid Beheshti University of Medical Sciences\",\"correspondingAuthor\":false,\"prefix\":\"\",\"firstName\":\"Eisa\",\"middleName\":\"\",\"lastName\":\"Fattah\",\"suffix\":\"\"},{\"id\":273596283,\"identity\":\"971f6603-3715-4bdd-a18a-f69714275370\",\"order_by\":5,\"name\":\"Fariba Bayat\",\"email\":\"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAABBklEQVRIiWNgGAWjYBAC9gYGhsMghgGYW8GQAJWQwKmF5wCylgNniNTCDNdysA2uBTfgYT/78HBBjR2DOfsZw88f59Xl6c5IYPzwg8EiH6cWnnSDwzOOJTNY9uQYSxzcdrjY7EYCs2QPg4RlAw4t9gxpDId52JgZDA7kGAC1HEjcdiOBQRroFwOctvA/A2r5V89gcP6N8Y+Dc+pAWph/49UiAbSFt+0wg8GNHDOJgw3MIC1s+G2RANoys+84j+WMZ2UWZ44B/XLmYZtljwE+h6Uxfy74Vi1nzp+8+UZFTV2e2fHkwzd+VNTh1ALXysDAAVPE2ABLDIQA+wOilI2CUTAKRsHIAwDnmVZ69WXRngAAAABJRU5ErkJggg==\",\"orcid\":\"\",\"institution\":\"Shahid Beheshti University of Medical Sciences\",\"correspondingAuthor\":true,\"prefix\":\"\",\"firstName\":\"Fariba\",\"middleName\":\"\",\"lastName\":\"Bayat\",\"suffix\":\"\"}],\"badges\":[],\"createdAt\":\"2024-02-17 15:16:03\",\"currentVersionCode\":1,\"declarations\":\"\",\"doi\":\"10.21203/rs.3.rs-3964434/v1\",\"doiUrl\":\"https://doi.org/10.21203/rs.3.rs-3964434/v1\",\"draftVersion\":[],\"editorialEvents\":[{\"content\":\"https://doi.org/10.1186/s13019-024-02885-7\",\"type\":\"published\",\"date\":\"2024-06-21T00:00:00+00:00\"}],\"editorialNote\":\"\",\"failedWorkflow\":false,\"files\":[{\"id\":51443176,\"identity\":\"0fc171df-84e4-46ce-96e8-980c72dd5e42\",\"added_by\":\"auto\",\"created_at\":\"2024-02-21 17:59:19\",\"extension\":\"jpeg\",\"order_by\":1,\"title\":\"Figure 1\",\"display\":\"\",\"copyAsset\":false,\"role\":\"figure\",\"size\":102900,\"visible\":true,\"origin\":\"\",\"legend\":\"\\u003cp\\u003eFindings of the transthoracic echocardiography show PMAIF: a) Four-chamber view of a PMAIF (arrow); size= 1.5 × 1.7 cm and b) Parasternal long-axis view of a PMAIF (arrow); size= 0.6 × 2.1 cm\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eLV:\\u003c/strong\\u003e left ventricle, \\u003cstrong\\u003eRV:\\u003c/strong\\u003e right ventricle, \\u003cstrong\\u003eRA:\\u003c/strong\\u003e right atrium, \\u003cstrong\\u003eLA:\\u003c/strong\\u003eleft atrium, \\u003cstrong\\u003eLVOT:\\u003c/strong\\u003e Left ventricular outflow tract, \\u003cstrong\\u003eAAo:\\u003c/strong\\u003e ascending aorta\\u003c/p\\u003e\",\"description\":\"\",\"filename\":\"floatimage1.jpeg\",\"url\":\"https://assets-eu.researchsquare.com/files/rs-3964434/v1/c1b83b2f4215546bddf20fbd.jpeg\"},{\"id\":51443177,\"identity\":\"23564db3-1e07-4795-8b90-4bf5ea8e61c2\",\"added_by\":\"auto\",\"created_at\":\"2024-02-21 17:59:19\",\"extension\":\"jpeg\",\"order_by\":2,\"title\":\"Figure 2\",\"display\":\"\",\"copyAsset\":false,\"role\":\"figure\",\"size\":190952,\"visible\":true,\"origin\":\"\",\"legend\":\"\\u003cp\\u003eContrast-enhanced computed tomography scan showing the PMAIF (arrow) in the axial plane,\\u003cstrong\\u003e LV:\\u003c/strong\\u003e left ventricle, \\u003cstrong\\u003eRV:\\u003c/strong\\u003e right ventricle, \\u003cstrong\\u003eRA:\\u003c/strong\\u003eright atrium, \\u003cstrong\\u003eLA:\\u003c/strong\\u003e left atrium\\u003c/p\\u003e\",\"description\":\"\",\"filename\":\"floatimage2.jpeg\",\"url\":\"https://assets-eu.researchsquare.com/files/rs-3964434/v1/20aa1dd323052ca58a9940e1.jpeg\"},{\"id\":58958949,\"identity\":\"adec7821-2ae9-453f-8324-e7fc47f6690f\",\"added_by\":\"auto\",\"created_at\":\"2024-06-24 15:42:38\",\"extension\":\"pdf\",\"order_by\":0,\"title\":\"\",\"display\":\"\",\"copyAsset\":false,\"role\":\"manuscript-pdf\",\"size\":906177,\"visible\":true,\"origin\":\"\",\"legend\":\"\",\"description\":\"\",\"filename\":\"manuscript.pdf\",\"url\":\"https://assets-eu.researchsquare.com/files/rs-3964434/v1/7edb72e2-5ee7-4978-9410-998372d4ce13.pdf\"},{\"id\":51443180,\"identity\":\"6348ab88-4837-4d0c-aa9d-2ae7d5e832ff\",\"added_by\":\"auto\",\"created_at\":\"2024-02-21 17:59:19\",\"extension\":\"mp4\",\"order_by\":1,\"title\":\"\",\"display\":\"\",\"copyAsset\":false,\"role\":\"supplement\",\"size\":494796,\"visible\":true,\"origin\":\"\",\"legend\":\"\\u003cp\\u003eSupplementary File 1 .mp4\\u0026nbsp;\\u003c/p\\u003e\\n\\u003cp\\u003eColor Doppler view of the PMAIF (arrow)\\u003c/p\\u003e\",\"description\":\"\",\"filename\":\"SupplementaryFile1.mp4\",\"url\":\"https://assets-eu.researchsquare.com/files/rs-3964434/v1/4fa52645bb7269ff84f0ae24.mp4\"},{\"id\":51443178,\"identity\":\"4c3a7463-68da-45be-81e6-4d7787201c7b\",\"added_by\":\"auto\",\"created_at\":\"2024-02-21 17:59:19\",\"extension\":\"xlsx\",\"order_by\":2,\"title\":\"\",\"display\":\"\",\"copyAsset\":false,\"role\":\"supplement\",\"size\":13147,\"visible\":true,\"origin\":\"\",\"legend\":\"\\u003cp\\u003eSupplementary File 2 .xls\\u0026nbsp;\\u003c/p\\u003e\\n\\u003cp\\u003eCharacteristics of 25 patients with PMAIF in published articles\\u003c/p\\u003e\",\"description\":\"\",\"filename\":\"SupplementaryFile2.xlsx\",\"url\":\"https://assets-eu.researchsquare.com/files/rs-3964434/v1/616e0c9dcc8b77cf8c843d5f.xlsx\"},{\"id\":51443181,\"identity\":\"77fcfda1-91b1-47e7-a76a-ad7ecd4f7c0f\",\"added_by\":\"auto\",\"created_at\":\"2024-02-21 17:59:20\",\"extension\":\"pdf\",\"order_by\":3,\"title\":\"\",\"display\":\"\",\"copyAsset\":false,\"role\":\"supplement\",\"size\":103315,\"visible\":true,\"origin\":\"\",\"legend\":\"\\u003cp\\u003eSupplementary File 3 .pdf\\u0026nbsp;\\u003c/p\\u003e\\n\\u003cp\\u003eCARE checklist\\u003c/p\\u003e\",\"description\":\"\",\"filename\":\"SupplementaryFile3.pdf\",\"url\":\"https://assets-eu.researchsquare.com/files/rs-3964434/v1/01ca4a9316d5fa35341d6d74.pdf\"}],\"financialInterests\":\"No competing interests reported.\",\"formattedTitle\":\"Thirty-three years follow-up of pseudoaneurysm of the mitral-aortic intervalvular fibrosa without surgical treatment: case report and literature review\",\"fulltext\":[{\"header\":\"Introduction\",\"content\":\"\\u003cp\\u003eThe disease known as pseudoaneurysm of the mitral-aortic intervalvular fibrosa (PMAIF) is a rare occurrence (\\u003cspan citationid=\\\"CR1\\\" class=\\\"CitationRef\\\"\\u003e1\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR2\\\" class=\\\"CitationRef\\\"\\u003e2\\u003c/span\\u003e). The PMAIF is identified as a delicate and fibrous membranous that is situated between the aortic valve root and the mitral valve (\\u003cspan citationid=\\\"CR3\\\" class=\\\"CitationRef\\\"\\u003e3\\u003c/span\\u003e). This area serves as the connection point between the noncoronary cusp of the aortic valve and the anterior mitral leaflet which communicates with the left ventricular outflow tract (\\u003cspan citationid=\\\"CR2\\\" class=\\\"CitationRef\\\"\\u003e2\\u003c/span\\u003e). The PMAIF is commonly found in individuals with aortic valve infective endocarditis or undergoing aortic valve replacement (AVR) (\\u003cspan citationid=\\\"CR4\\\" class=\\\"CitationRef\\\"\\u003e4\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR5\\\" class=\\\"CitationRef\\\"\\u003e5\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR6\\\" class=\\\"CitationRef\\\"\\u003e6\\u003c/span\\u003e).\\u003c/p\\u003e \\u003cp\\u003eThe prognostication of PMAIF's clinical and surgical outcomes is challenging. It can be asymptomatic and uncomplicated or associated with complications such as rupture, embolization, and compression of vital (\\u003cspan citationid=\\\"CR7\\\" class=\\\"CitationRef\\\"\\u003e7\\u003c/span\\u003e). The occurrence of PMAIF rupture into the pericardium can be life-threatening (\\u003cspan citationid=\\\"CR8\\\" class=\\\"CitationRef\\\"\\u003e8\\u003c/span\\u003e). Therefore, when a PMAIF is identified, surgical intervention is commonly advised to all patients, regardless of their lack of symptoms (\\u003cspan citationid=\\\"CR7\\\" class=\\\"CitationRef\\\"\\u003e7\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR8\\\" class=\\\"CitationRef\\\"\\u003e8\\u003c/span\\u003e). The surgical repair of PMAIF commonly involves aortic valve replacement or aortic root surgery and the presence of comorbidities can be contraindications for this surgery (\\u003cspan citationid=\\\"CR8\\\" class=\\\"CitationRef\\\"\\u003e8\\u003c/span\\u003e). Alternatively, a conservative therapeutic approach may be considered (\\u003cspan citationid=\\\"CR7\\\" class=\\\"CitationRef\\\"\\u003e7\\u003c/span\\u003e). Therefore, for these patients, close clinical observations and echocardiographic evaluations are necessary. The utilization of both transthoracic echocardiography (TTE) and transesophageal echocardiography (TEE) is recommended for all follow-up evaluations (\\u003cspan citationid=\\\"CR8\\\" class=\\\"CitationRef\\\"\\u003e8\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR9\\\" class=\\\"CitationRef\\\"\\u003e9\\u003c/span\\u003e).\\u003c/p\\u003e \\u003cp\\u003eThis case report aims to gather limited evidence on experiences with PMAIF non-surgical management. This study describes a 33-year follow-up of a PMAIF in a patient with a prosthetic metallic aortic valve without experiencing any adverse clinical occurrences during follow-up.\\u003c/p\\u003e\"},{\"header\":\"Case presentation\",\"content\":\"\\u003cp\\u003eThe case describes a man who was born in the year 1960 and received a prosthetic metallic aortic valve due to severe aortic stenosis at the age of 25. He had no other significant past medical history except cranial surgery due to extradural hematoma after a trauma in 1984 which had no damage to his chest. He has been treated with warfarin 5 mg daily ever since with an International normalized ratio (INR) of 2.5. Also, echocardiography was performed annually and ejection fraction (EF) was around 50% through those years of follow-up.\\u003c/p\\u003e \\u003cp\\u003eAfter six years following AVR, he started complaining of worsening dyspnea. He was referred to our center for the first time and in the work-up the echocardiography showed an EF of 20% with PMAIF with the size of 7 \\u0026times; 10 mm. During the consultation with cardiac surgery, he was informed that he needed to repair the pseudoaneurysm, however, he eventually refused to receive the surgery since he was afraid of high-risk procedure outcomes. Therefore, conservative treatment with close observation was initiated for him. The medical treatment for heart failure included losartan 25 mg daily, carvedilol 6.25 mg bd, furosemide 40 mg daily, and spironolactone 25 mg daily. Every three to six months blood profiles including INR were checked. Additionally, every six to 12 months his echocardiography was followed. In some instances, TEE was performed to determine PMAIF changes better.\\u003c/p\\u003e \\u003cp\\u003eHe has been followed up for 33 years and interestingly his prosthetic valve remained functional. Regular follow-up TTE which is presented in Table\\u0026nbsp;\\u003cspan refid=\\\"Tab1\\\" class=\\\"InternalRef\\\"\\u003e1\\u003c/span\\u003e, shows a minimal increase in the size of PMAIF with a stable EF in the range of 25\\u0026ndash;30% during the recent years. Figure\\u0026nbsp;\\u003cspan refid=\\\"Fig1\\\" class=\\\"InternalRef\\\"\\u003e1\\u003c/span\\u003e displays a TTE image of the patient. Also, the color Doppler echocardiography demonstrates the flow going to and fro in the PMAIF during systole and diastole (flow direction is marked by an arrow) shown in Supplementary File 1. Furthermore, a contrast-enhanced computed tomography scan demonstrates the characteristic appearance of a PMAIF, as shown in Fig.\\u0026nbsp;\\u003cspan refid=\\\"Fig2\\\" class=\\\"InternalRef\\\"\\u003e2\\u003c/span\\u003e. Finally, He had no complications such as a cerebrovascular accident. He is still working as a salesman and is satisfied with his quality of life since his symptoms such as dyspnea have improved significantly.\\u003c/p\\u003e \\u003cp\\u003e \\u003cdiv class=\\\"gridtable\\\"\\u003e\\u003ctable float=\\\"Yes\\\" id=\\\"Tab1\\\" border=\\\"1\\\"\\u003e \\u003ccaption language=\\\"En\\\"\\u003e \\u003cdiv class=\\\"CaptionNumber\\\"\\u003eTable 1\\u003c/div\\u003e \\u003cdiv class=\\\"CaptionContent\\\"\\u003e \\u003cp\\u003eEchocardiography characteristics through 33 years of follow-up\\u003c/p\\u003e \\u003c/div\\u003e \\u003c/caption\\u003e \\u003ccolgroup cols=\\\"7\\\"\\u003e \\u003cdiv align=\\\"left\\\" class=\\\"colspec\\\" colname=\\\"c1\\\" colnum=\\\"1\\\"\\u003e\\u003c/div\\u003e \\u003cdiv align=\\\"left\\\" class=\\\"colspec\\\" colname=\\\"c2\\\" colnum=\\\"2\\\"\\u003e\\u003c/div\\u003e \\u003cdiv align=\\\"left\\\" class=\\\"colspec\\\" colname=\\\"c3\\\" colnum=\\\"3\\\"\\u003e\\u003c/div\\u003e \\u003cdiv align=\\\"left\\\" class=\\\"colspec\\\" colname=\\\"c4\\\" colnum=\\\"4\\\"\\u003e\\u003c/div\\u003e \\u003cdiv align=\\\"left\\\" class=\\\"colspec\\\" colname=\\\"c5\\\" colnum=\\\"5\\\"\\u003e\\u003c/div\\u003e \\u003cdiv align=\\\"left\\\" class=\\\"colspec\\\" colname=\\\"c6\\\" colnum=\\\"6\\\"\\u003e\\u003c/div\\u003e \\u003cdiv align=\\\"left\\\" class=\\\"colspec\\\" colname=\\\"c7\\\" colnum=\\\"7\\\"\\u003e\\u003c/div\\u003e \\u003cthead\\u003e \\u003ctr\\u003e \\u003cth align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eDate\\u003c/p\\u003e \\u003c/th\\u003e \\u003cth align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003eEchocardiography\\u003c/p\\u003e \\u003c/th\\u003e \\u003cth align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003eLVEF\\u003c/p\\u003e \\u003c/th\\u003e \\u003cth align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003ePMAIF Size\\u003c/p\\u003e \\u003c/th\\u003e \\u003cth align=\\\"left\\\" colname=\\\"c5\\\"\\u003e \\u003cp\\u003eFunction of mechanical aortic valve\\u003c/p\\u003e \\u003c/th\\u003e \\u003cth align=\\\"left\\\" colname=\\\"c6\\\"\\u003e \\u003cp\\u003eValvular disease\\u003c/p\\u003e \\u003c/th\\u003e \\u003cth align=\\\"left\\\" colname=\\\"c7\\\"\\u003e \\u003cp\\u003ePAP\\u003c/p\\u003e \\u003c/th\\u003e \\u003c/tr\\u003e \\u003c/thead\\u003e \\u003ctbody\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003e7/24/1991\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003eTTE\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e20%\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e7 \\u0026times; 10 mm\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c5\\\"\\u003e \\u003cp\\u003eN/A\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c6\\\"\\u003e \\u003cp\\u003eN/A\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c7\\\"\\u003e \\u003cp\\u003eN/A\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003e10/05/2014\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003eTEE\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e25\\u0026ndash;30%\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003eCommunication with LVOT\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c5\\\"\\u003e \\u003cp\\u003ePPG: 44 mmHg\\u003c/p\\u003e \\u003cp\\u003eMPG: 27 mmHg\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c6\\\"\\u003e \\u003cp\\u003eMild MR\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c7\\\"\\u003e \\u003cp\\u003e25 mmHg\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003e09/07/2015\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003eTTE\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e25%\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003eN/A\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c5\\\"\\u003e \\u003cp\\u003ePPG:36 mmHg\\u003c/p\\u003e \\u003cp\\u003eMPG: 17 mmHg\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c6\\\"\\u003e \\u003cp\\u003eMR\\u003c/p\\u003e \\u003cp\\u003eTR\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c7\\\"\\u003e \\u003cp\\u003eN/A\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003e09/15/2016\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003eTTE\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e30\\u0026ndash;35%\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003eN/A\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c5\\\"\\u003e \\u003cp\\u003eN/A\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c6\\\"\\u003e \\u003cp\\u003eMR\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c7\\\"\\u003e \\u003cp\\u003eN/A\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003e06/13/2017\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003eTTE\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e35%\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003eN/A\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c5\\\"\\u003e \\u003cp\\u003ePPG: 45 mmHg\\u003c/p\\u003e \\u003cp\\u003eMPG: 26 mmHg\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c6\\\"\\u003e \\u003cp\\u003eMR\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c7\\\"\\u003e \\u003cp\\u003eN/A\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003e07/22/2018\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003eTTE\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e20\\u0026ndash;25%\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003eN/A\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c5\\\"\\u003e \\u003cp\\u003ePPG: 40 mmHg\\u003c/p\\u003e \\u003cp\\u003eMPG: 20 mmHg\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c6\\\"\\u003e \\u003cp\\u003eMild MR\\u003c/p\\u003e \\u003cp\\u003eMild TR\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c7\\\"\\u003e \\u003cp\\u003eNormal\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003e05/09/2019\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e3D TDI\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e20\\u0026ndash;25%\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e9 \\u0026times; 13 mm\\u003c/p\\u003e \\u003cp\\u003eNo leakage\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c5\\\"\\u003e \\u003cp\\u003eN/A\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c6\\\"\\u003e \\u003cp\\u003eMild MR\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c7\\\"\\u003e \\u003cp\\u003eN/A\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003e06/27/2020\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e3D TEE\\u0026thinsp;+\\u0026thinsp;TTE\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e30\\u0026ndash;35%\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e11.3 \\u0026times; 15.9 mm\\u003c/p\\u003e \\u003cp\\u003eMild leakage\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c5\\\"\\u003e \\u003cp\\u003eN/A\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c6\\\"\\u003e \\u003cp\\u003eN/A\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c7\\\"\\u003e \\u003cp\\u003eN/A\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003e06/16/2021\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003eTDI\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e25\\u0026ndash;30%\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e13 \\u0026times; 18 mm\\u003c/p\\u003e \\u003cp\\u003eNo connection\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c5\\\"\\u003e \\u003cp\\u003ePPG: 36 mmHg\\u003c/p\\u003e \\u003cp\\u003eMPG: 22 mmHg\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c6\\\"\\u003e \\u003cp\\u003eMild MR\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c7\\\"\\u003e \\u003cp\\u003eNormal\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003e07/14/2022\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003eTDI\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e30%\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e16 \\u0026times; 20 mm\\u003c/p\\u003e \\u003cp\\u003eConnection to LVOT (diameter 3 mm)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c5\\\"\\u003e \\u003cp\\u003ePPG: 32 mmHg\\u003c/p\\u003e \\u003cp\\u003eMPG: 19 mmHg\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c6\\\"\\u003e \\u003cp\\u003eMild MR\\u003c/p\\u003e \\u003cp\\u003eMild to moderate TR\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c7\\\"\\u003e \\u003cp\\u003e25 mmHg\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003e04/17/2023\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003eTDI\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e30%\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e15 \\u0026times; 17 mm\\u003c/p\\u003e \\u003cp\\u003eOrifice 4.5 mm\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c5\\\"\\u003e \\u003cp\\u003ePPG: 30 mmHg\\u003c/p\\u003e \\u003cp\\u003eMPG: 17 mmHg\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c6\\\"\\u003e \\u003cp\\u003eMild MR\\u003c/p\\u003e \\u003cp\\u003eMild TR\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c7\\\"\\u003e \\u003cp\\u003e30 mmHg\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003c/tbody\\u003e \\u003c/colgroup\\u003e \\u003ctfoot\\u003e \\u003ctr\\u003e\\u003ctd colspan=\\\"7\\\"\\u003e\\u003cb\\u003eTEE\\u003c/b\\u003e: Transoesophageal echocardiography, \\u003cb\\u003eTTE\\u003c/b\\u003e: Transthoracic echocardiogram, \\u003cb\\u003emm\\u003c/b\\u003e: Millimetre, \\u003cb\\u003eN/A\\u003c/b\\u003e: Not available, \\u003cb\\u003ePAP\\u003c/b\\u003e: pulmonary artery pressure, \\u003cb\\u003eMR\\u003c/b\\u003e: Mitral regurgitation, \\u003cb\\u003eTR\\u003c/b\\u003e: Tricuspid regurgitation, \\u003cb\\u003ePPG\\u003c/b\\u003e: peak pressure gradient, \\u003cb\\u003eMPG\\u003c/b\\u003e: mean pressure gradient, \\u003cb\\u003eLVOT\\u003c/b\\u003e: Left ventricular outflow tract, \\u003cb\\u003eLVEF\\u003c/b\\u003e: Left ventricular ejection fraction, \\u003cb\\u003eTDI\\u003c/b\\u003e: Tissue Doppler imaging\\u003c/td\\u003e\\u003c/tr\\u003e \\u003c/tfoot\\u003e \\u003c/table\\u003e\\u003c/div\\u003e \\u003c/p\\u003e \\u003cp\\u003e \\u003c/p\\u003e \\u003cp\\u003e \\u003c/p\\u003e\\n\\u003ch3\\u003ePatient Perspective\\u003c/h3\\u003e\\n\\u003cp\\u003e\\u0026ldquo;\\u003cem\\u003eAfter being diagnosed with a PMAIF, I faced a critical decision regarding whether to proceed with corrective surgery or continue with non-surgical treatments. Having weighed the pros and cons carefully, and considering both options thoroughly, I ultimately chose the conservative based on several factors. As a salesman, I take pride in staying active and managing my condition responsibly. Thanks to proper medications, consistent care, and effective communication with healthcare providers, I can lead an ordinary life despite the challenges posed by my heart condition. It brings me great joy knowing that my symptoms, particularly shortness of breath, have considerably improved over time, contributing positively to my overall well-being and happiness. I managed to preserve an acceptable standard of living, performing my job duties efficiently and enjoying leisure activities without undue restrictions.\\u003c/em\\u003e\\u0026rdquo;\\u003c/p\\u003e\"},{\"header\":\"Discussion and literature review\",\"content\":\"\\u003cp\\u003eA PMAIF \\u0026nbsp;is a recognized issue associated with both infective endocarditis of the aortic valve and artificial aortic valve implantation\\u0026nbsp;(10). While larger instances of PMAIF might be identified through TTE\\u0026nbsp;(8), the diagnosis of a PMAIF \\u0026nbsp;typically necessitates TEE\\u0026nbsp;(11). There have been recent advancements in the diagnostic methods for PMAIF, such as three-dimensional echocardiography, cardiac CT-scan, and MRI. However, it remains unclear what additional value these techniques offer compared to the standard two-dimensional TEE\\u0026nbsp;(12).\\u003c/p\\u003e\\n\\u003cp\\u003eThe occurrence of complications may arise occasionally, but it is also possible for PMAIF to persist without complications or symptoms for indeterminate periods. These include the rupture into the left atrium or aorta, localized compression of a coronary artery causing myocardial ischemia, distortion of the mitral valve leading to mitral regurgitation, and the development of blood clots and subsequent distal embolization\\u0026nbsp;(13).\\u003c/p\\u003e\\n\\u003cp\\u003eOperative correction is frequently advised for managing PMAIF, yet the optimal therapy remains uncertain. In particular, the indication and timing of the surgical procedure continue to be a matter of debate. In many cases that have been recorded before, the recognition of a PMAIF required carrying out a surgical operation. Surgical procedures tend to be complicated and high-risk, often involving aortic valve replacement (often repeated valve replacement), repair of the aortic root, and restoration of the mitral-aortic intervalvular fibrosa\\u0026nbsp;(11).\\u003c/p\\u003e\\n\\u003cp\\u003eReports of conservative management of PMAIF without surgical intervention are limited. However, there are instances in earlier studies where patients with PMAIF refused surgery and remained asymptomatic and in good health throughout follow-up periods. These cases generally showed favorable outcomes without experiencing adverse effects\\u0026nbsp;(14).\\u003c/p\\u003e\\n\\u003cp\\u003eThe literature review includes 13 articles that report non-surgical methods for managing PMAIF, which are shown in Table 2. These studies cover a total of 25 patients from the years 2008 to 2022 and can be found in supplementary file 2. A significant portion of the patients were male, accounting for 17 out of the 25 cases documented. The age range of patients is quite broad, from 1 month up to 87 years old, indicating the diverse age groups needing cardiac diagnostics and interventions. Of all the patients, 9 men underwent some form of surgery. These surgeries include aortic valve replacement, mechanical valve implant, coronary artery bypass grafting, aortic valvotomy, resection for subaortic stenosis, and the Bentall procedure. In addition, 5 surgeries are reported for female patients, which include ventricular septal defect repair, aortic valve replacement, and composite graft replacement of the ascending aorta. Endocarditis was absent in most cases. However, three patients had past histories of endocarditis before their latest evaluations: two males aged 55 and 77 years old, and one female aged 87 years old\\u0026nbsp;(7, 8, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25).\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eTable 2.\\u003c/strong\\u003e Demographic, clinical characteristics and follow-up of patients with PMAIF in published articles\\u003c/p\\u003e\\n\\u003ctable border=\\\"1\\\" cellspacing=\\\"0\\\" cellpadding=\\\"0\\\" width=\\\"768\\\"\\u003e\\n \\u003ctbody\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd width=\\\"11.71875%\\\"\\u003e\\n \\u003cp\\u003e\\u003cstrong\\u003eFirst author (year)\\u003c/strong\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd width=\\\"17.96875%\\\"\\u003e\\n \\u003cp\\u003e\\u003cstrong\\u003eCharacteristics (Number of Cases / Age / Sex)\\u003c/strong\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd width=\\\"19.53125%\\\"\\u003e\\n \\u003cp\\u003e\\u003cstrong\\u003ePrior surgery / Endocarditis\\u003c/strong\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd width=\\\"21.875%\\\"\\u003e\\n \\u003cp\\u003e\\u003cstrong\\u003eSymptoms / Diagnosis\\u003c/strong\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd width=\\\"9.375%\\\"\\u003e\\n \\u003cp\\u003e\\u003cstrong\\u003eSize (mm)\\u003c/strong\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd width=\\\"19.53125%\\\"\\u003e\\n \\u003cp\\u003e\\u003cstrong\\u003eFollow-up (year/size changes/complications)\\u003c/strong\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd width=\\\"11.71875%\\\"\\u003e\\n \\u003cp\\u003eBishara \\u003cem\\u003eet al.\\u0026nbsp;\\u003c/em\\u003e(2022)\\u0026nbsp;(16)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd width=\\\"17.96875%\\\"\\u003e\\n \\u003cul\\u003e\\n \\u003cli\\u003eOne\\u003c/li\\u003e\\n \\u003cli\\u003e16 y\\u003c/li\\u003e\\n \\u003cli\\u003emale\\u003c/li\\u003e\\n \\u003c/ul\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd width=\\\"19.53125%\\\"\\u003e\\n \\u003cul\\u003e\\n \\u003cli\\u003eNone\\u003c/li\\u003e\\n \\u003cli\\u003eNone\\u003c/li\\u003e\\n \\u003c/ul\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd width=\\\"21.875%\\\"\\u003e\\n \\u003cul\\u003e\\n \\u003cli\\u003eNone\\u0026nbsp;\\u003c/li\\u003e\\n \\u003cli\\u003eTTE and TEE\\u003c/li\\u003e\\n \\u003c/ul\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd width=\\\"9.375%\\\"\\u003e\\n \\u003cp\\u003eN/A\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd width=\\\"19.53125%\\\"\\u003e\\n \\u003cul\\u003e\\n \\u003cli\\u003e3 years\\u003c/li\\u003e\\n \\u003cli\\u003eMinor Changes\\u003c/li\\u003e\\n \\u003cli\\u003eNone\\u003c/li\\u003e\\n \\u003c/ul\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd width=\\\"11.71875%\\\"\\u003e\\n \\u003cp\\u003eNiwano \\u003cem\\u003eet al.\\u003c/em\\u003e (2021)\\u0026nbsp;(22)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd width=\\\"17.96875%\\\"\\u003e\\n \\u003cul\\u003e\\n \\u003cli\\u003eOne\\u003c/li\\u003e\\n \\u003cli\\u003e76 y\\u003c/li\\u003e\\n \\u003cli\\u003efemale\\u003c/li\\u003e\\n \\u003c/ul\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd width=\\\"19.53125%\\\"\\u003e\\n \\u003cul\\u003e\\n \\u003cli\\u003eAVR\\u003c/li\\u003e\\n \\u003cli\\u003eNone\\u003c/li\\u003e\\n \\u003c/ul\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd width=\\\"21.875%\\\"\\u003e\\n \\u003cul\\u003e\\n \\u003cli\\u003eNone\\u003c/li\\u003e\\n \\u003cli\\u003eTTE, TEE, MRI, and CT-Scan\\u003c/li\\u003e\\n \\u003c/ul\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd width=\\\"9.375%\\\"\\u003e\\n \\u003cp\\u003eN/A\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd width=\\\"19.53125%\\\"\\u003e\\n \\u003cul\\u003e\\n \\u003cli\\u003e30 years\\u003c/li\\u003e\\n \\u003cli\\u003eMinor Changes\\u003c/li\\u003e\\n \\u003cli\\u003eBeh\\u0026ccedil;et\\u0026rsquo;s\\u0026nbsp;disease\\u003c/li\\u003e\\n \\u003c/ul\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd width=\\\"11.71875%\\\"\\u003e\\n \\u003cp\\u003eDel Pasqua \\u003cem\\u003eet al.\\u003c/em\\u003e (2018)\\u0026nbsp;(18)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd width=\\\"17.96875%\\\"\\u003e\\n \\u003cul\\u003e\\n \\u003cli\\u003eOne\\u003c/li\\u003e\\n \\u003cli\\u003e1 month\\u003c/li\\u003e\\n \\u003cli\\u003efemale\\u003c/li\\u003e\\n \\u003c/ul\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd width=\\\"19.53125%\\\"\\u003e\\n \\u003cul\\u003e\\n \\u003cli\\u003eNone\\u003c/li\\u003e\\n \\u003cli\\u003eNone\\u003c/li\\u003e\\n \\u003c/ul\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd width=\\\"21.875%\\\"\\u003e\\n \\u003cul\\u003e\\n \\u003cli\\u003eInnocent murmur\\u003c/li\\u003e\\n \\u003cli\\u003eTTE, TEE, and CT-Scan\\u003c/li\\u003e\\n \\u003c/ul\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd width=\\\"9.375%\\\"\\u003e\\n \\u003cp\\u003e7 \\u0026times; 6 mm\\u003c/p\\u003e\\n \\u003cp\\u003e\\u0026nbsp;\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd width=\\\"19.53125%\\\"\\u003e\\n \\u003cul\\u003e\\n \\u003cli\\u003e5 years\\u003c/li\\u003e\\n \\u003cli\\u003e12 \\u0026times; 10 mm (Max Diameter)\\u003c/li\\u003e\\n \\u003cli\\u003eNone\\u003c/li\\u003e\\n \\u003c/ul\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd width=\\\"11.71875%\\\"\\u003e\\n \\u003cp\\u003eCaro-Dominguez \\u003cem\\u003eet al.\\u0026nbsp;\\u003c/em\\u003e(2017)\\u0026nbsp;(17)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd width=\\\"17.96875%\\\"\\u003e\\n \\u003cul\\u003e\\n \\u003cli\\u003eOne\\u003c/li\\u003e\\n \\u003cli\\u003e13 y\\u003c/li\\u003e\\n \\u003cli\\u003emale\\u003c/li\\u003e\\n \\u003c/ul\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd width=\\\"19.53125%\\\"\\u003e\\n \\u003cul\\u003e\\n \\u003cli\\u003eNone\\u003c/li\\u003e\\n \\u003cli\\u003eNone\\u003c/li\\u003e\\n \\u003c/ul\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd width=\\\"21.875%\\\"\\u003e\\n \\u003cul\\u003e\\n \\u003cli\\u003eChest Pain\\u003c/li\\u003e\\n \\u003cli\\u003eTTE and MRI\\u003c/li\\u003e\\n \\u003c/ul\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd width=\\\"9.375%\\\"\\u003e\\n \\u003cp\\u003eN/A\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd width=\\\"19.53125%\\\"\\u003e\\n \\u003cul\\u003e\\n \\u003cli\\u003e6 months\\u003c/li\\u003e\\n \\u003cli\\u003eMinor Changes\\u003c/li\\u003e\\n \\u003cli\\u003eNone\\u003c/li\\u003e\\n \\u003c/ul\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd width=\\\"11.71875%\\\"\\u003e\\n \\u003cp\\u003eLow \\u003cem\\u003eet al.\\u0026nbsp;\\u003c/em\\u003e(2017)\\u0026nbsp;(21)\\u0026nbsp;\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd width=\\\"17.96875%\\\"\\u003e\\n \\u003cul\\u003e\\n \\u003cli\\u003eFive\\u003c/li\\u003e\\n \\u003cli\\u003eranged from 18 to 64 y\\u003c/li\\u003e\\n \\u003cli\\u003efive males\\u003c/li\\u003e\\n \\u003c/ul\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd width=\\\"19.53125%\\\"\\u003e\\n \\u003cul\\u003e\\n \\u003cli\\u003eMechanical valve: One case\\u003c/li\\u003e\\n \\u003cli\\u003eNone\\u003c/li\\u003e\\n \\u003c/ul\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd width=\\\"21.875%\\\"\\u003e\\n \\u003cul\\u003e\\n \\u003cli\\u003eArrhythmia: two cases\\u003c/li\\u003e\\n \\u003cli\\u003eTEE: Four cases\\u003cbr\\u003e\\u0026nbsp;TTE, MRI, and CT: Five cases\\u003c/li\\u003e\\n \\u003c/ul\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd width=\\\"9.375%\\\"\\u003e\\n \\u003cp\\u003eRanged from\\u0026nbsp;16 to 52 mm\\u003c/p\\u003e\\n \\u003cp\\u003e(Mean:29 \\u0026plusmn; 13 mm)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd width=\\\"19.53125%\\\"\\u003e\\n \\u003cul\\u003e\\n \\u003cli\\u003e4 years\\u003c/li\\u003e\\n \\u003cli\\u003eMinor Changes\\u003c/li\\u003e\\n \\u003cli\\u003eNone\\u003c/li\\u003e\\n \\u003c/ul\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd width=\\\"11.71875%\\\"\\u003e\\n \\u003cp\\u003eApostolidou \\u003cem\\u003eet al.,\\u003c/em\\u003e (2017)\\u0026nbsp;(15)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd width=\\\"17.96875%\\\"\\u003e\\n \\u003cul\\u003e\\n \\u003cli\\u003eOne\\u003c/li\\u003e\\n \\u003cli\\u003e84 y\\u003c/li\\u003e\\n \\u003cli\\u003eMale\\u003c/li\\u003e\\n \\u003c/ul\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd width=\\\"19.53125%\\\"\\u003e\\n \\u003cul\\u003e\\n \\u003cli\\u003eCABG\\u003c/li\\u003e\\n \\u003cli\\u003eNone\\u003c/li\\u003e\\n \\u003c/ul\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd width=\\\"21.875%\\\"\\u003e\\n \\u003cul\\u003e\\n \\u003cli\\u003eDyspnea\\u003c/li\\u003e\\n \\u003cli\\u003eTEE\\u003c/li\\u003e\\n \\u003c/ul\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd width=\\\"9.375%\\\"\\u003e\\n \\u003cp\\u003eN/A\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd width=\\\"19.53125%\\\"\\u003e\\n \\u003cul\\u003e\\n \\u003cli\\u003e15 months\\u003c/li\\u003e\\n \\u003cli\\u003eN/A\\u003c/li\\u003e\\n \\u003cli\\u003eNone\\u003c/li\\u003e\\n \\u003c/ul\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd width=\\\"11.71875%\\\"\\u003e\\n \\u003cp\\u003eHan \\u003cem\\u003eet al\\u003c/em\\u003e. (2016)\\u0026nbsp;(20)\\u0026nbsp;\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd width=\\\"17.96875%\\\"\\u003e\\n \\u003cul\\u003e\\n \\u003cli\\u003eOne\\u003c/li\\u003e\\n \\u003cli\\u003e27 y\\u003c/li\\u003e\\n \\u003cli\\u003eMale\\u003c/li\\u003e\\n \\u003c/ul\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd width=\\\"19.53125%\\\"\\u003e\\n \\u003cul\\u003e\\n \\u003cli\\u003eNone\\u003c/li\\u003e\\n \\u003cli\\u003eNone\\u003c/li\\u003e\\n \\u003c/ul\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd width=\\\"21.875%\\\"\\u003e\\n \\u003cul\\u003e\\n \\u003cli\\u003eNone\\u0026nbsp;\\u003c/li\\u003e\\n \\u003cli\\u003eTTE\\u003c/li\\u003e\\n \\u003c/ul\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd width=\\\"9.375%\\\"\\u003e\\n \\u003cp\\u003e8 \\u0026times; 12 mm\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd width=\\\"19.53125%\\\"\\u003e\\n \\u003cul\\u003e\\n \\u003cli\\u003e3 years\\u003c/li\\u003e\\n \\u003cli\\u003eMinor Changes\\u003c/li\\u003e\\n \\u003cli\\u003eNone\\u003c/li\\u003e\\n \\u003c/ul\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd width=\\\"11.71875%\\\"\\u003e\\n \\u003cp\\u003eMaria Bonou \\u003cem\\u003eet al\\u003c/em\\u003e. (2015)\\u0026nbsp;(25)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd width=\\\"17.96875%\\\"\\u003e\\n \\u003cul\\u003e\\n \\u003cli\\u003eTwo\\u003c/li\\u003e\\n \\u003cli\\u003e42 y and 77 y\\u003c/li\\u003e\\n \\u003cli\\u003eone male and one female\\u003c/li\\u003e\\n \\u003c/ul\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd width=\\\"19.53125%\\\"\\u003e\\n \\u003cul\\u003e\\n \\u003cli\\u003eAVR: Two cases,\\u003cbr\\u003e\\u0026nbsp;CABG: one case\\u003c/li\\u003e\\n \\u003cli\\u003eEndocarditis: One case\\u003c/li\\u003e\\n \\u003c/ul\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd width=\\\"21.875%\\\"\\u003e\\n \\u003cul\\u003e\\n \\u003cli\\u003eDOE and Palpitations: One case,\\u003cbr\\u003e\\u0026nbsp;Fever: One case\\u003c/li\\u003e\\n \\u003cli\\u003eTTE: One case\\u003cbr\\u003e\\u0026nbsp;TEE and CT: Tow cases\\u003c/li\\u003e\\n \\u003c/ul\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd width=\\\"9.375%\\\"\\u003e\\n \\u003cul\\u003e\\n \\u003cli\\u003e33 mm\\u003c/li\\u003e\\n \\u003cli\\u003e22 mm\\u003c/li\\u003e\\n \\u003c/ul\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd width=\\\"19.53125%\\\"\\u003e\\n \\u003cul\\u003e\\n \\u003cli\\u003e3-4 years\\u003c/li\\u003e\\n \\u003cli\\u003eMinor Changes\\u003c/li\\u003e\\n \\u003cli\\u003eNone\\u003c/li\\u003e\\n \\u003c/ul\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd width=\\\"11.71875%\\\"\\u003e\\n \\u003cp\\u003eŞahan \\u003cem\\u003eet al.\\u003c/em\\u003e (2014)\\u0026nbsp;(8)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd width=\\\"17.96875%\\\"\\u003e\\n \\u003cul\\u003e\\n \\u003cli\\u003eThree\\u003c/li\\u003e\\n \\u003cli\\u003eranged from 23 to 71 y\\u003c/li\\u003e\\n \\u003cli\\u003eone male and two female\\u003c/li\\u003e\\n \\u003c/ul\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd width=\\\"19.53125%\\\"\\u003e\\n \\u003cul\\u003e\\n \\u003cli\\u003eNone\\u003c/li\\u003e\\n \\u003cli\\u003eNone\\u003c/li\\u003e\\n \\u003c/ul\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd width=\\\"21.875%\\\"\\u003e\\n \\u003cul\\u003e\\n \\u003cli\\u003eNone\\u0026nbsp;\\u003c/li\\u003e\\n \\u003cli\\u003eTTE and TEE: All cases\\u003c/li\\u003e\\n \\u003c/ul\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd width=\\\"9.375%\\\"\\u003e\\n \\u003cul\\u003e\\n \\u003cli\\u003e21 \\u0026times; 11 mm\\u003c/li\\u003e\\n \\u003cli\\u003e12 \\u0026times; 31 mm\\u003c/li\\u003e\\n \\u003cli\\u003e27 \\u0026times; 21 mm\\u003c/li\\u003e\\n \\u003c/ul\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd width=\\\"19.53125%\\\"\\u003e\\n \\u003cul\\u003e\\n \\u003cli\\u003e3 years\\u003c/li\\u003e\\n \\u003cli\\u003e49 \\u0026times; 78 mm in the second case,\\u0026nbsp;\\u003cbr\\u003e\\u0026nbsp;minor changes in others\\u0026nbsp;\\u003c/li\\u003e\\n \\u003cli\\u003eTakayasu in one case\\u003c/li\\u003e\\n \\u003c/ul\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd width=\\\"11.71875%\\\"\\u003e\\n \\u003cp\\u003eHasin \\u003cem\\u003eet al.\\u003c/em\\u003e (2011)\\u0026nbsp;(7)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd width=\\\"17.96875%\\\"\\u003e\\n \\u003cul\\u003e\\n \\u003cli\\u003eTwo\\u003c/li\\u003e\\n \\u003cli\\u003e43 y and 55 y\\u003c/li\\u003e\\n \\u003cli\\u003eTwo male\\u003c/li\\u003e\\n \\u003c/ul\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd width=\\\"19.53125%\\\"\\u003e\\n \\u003cul\\u003e\\n \\u003cli\\u003eAVR: One case,\\u003cbr\\u003e\\u0026nbsp;Aortic valvotomy: One case\\u0026nbsp;\\u003c/li\\u003e\\n \\u003cli\\u003eOne case endocarditis\\u003c/li\\u003e\\n \\u003c/ul\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd width=\\\"21.875%\\\"\\u003e\\n \\u003cul\\u003e\\n \\u003cli\\u003eNone\\u0026nbsp;\\u003c/li\\u003e\\n \\u003cli\\u003eTTE: One case\\u003cbr\\u003e\\u0026nbsp;TEE: Two Cases\\u003c/li\\u003e\\n \\u003c/ul\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd width=\\\"9.375%\\\"\\u003e\\n \\u003cul\\u003e\\n \\u003cli\\u003e40 mm\\u003c/li\\u003e\\n \\u003cli\\u003e60 mm\\u003c/li\\u003e\\n \\u003c/ul\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd width=\\\"19.53125%\\\"\\u003e\\n \\u003cul\\u003e\\n \\u003cli\\u003e5-16 years\\u003c/li\\u003e\\n \\u003cli\\u003e48 mm and 68 mm in order\\u003c/li\\u003e\\n \\u003cli\\u003eNone\\u003c/li\\u003e\\n \\u003c/ul\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd width=\\\"11.71875%\\\"\\u003e\\n \\u003cp\\u003eGin \\u003cem\\u003eet al.\\u0026nbsp;\\u003c/em\\u003e(2011)\\u0026nbsp;(19)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd width=\\\"17.96875%\\\"\\u003e\\n \\u003cul\\u003e\\n \\u003cli\\u003eThree\\u003c/li\\u003e\\n \\u003cli\\u003eranged from 31 to 87 y\\u003c/li\\u003e\\n \\u003cli\\u003eone male and two female\\u003c/li\\u003e\\n \\u003c/ul\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd width=\\\"19.53125%\\\"\\u003e\\n \\u003cul\\u003e\\n \\u003cli\\u003eAVR: One case,\\u003cbr\\u003e\\u0026nbsp;VSD Repair and Resection SAoS: one case\\u003c/li\\u003e\\n \\u003cli\\u003eEndocarditis: One case\\u003c/li\\u003e\\n \\u003c/ul\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd width=\\\"21.875%\\\"\\u003e\\n \\u003cul\\u003e\\n \\u003cli\\u003eNone\\u0026nbsp;\\u003c/li\\u003e\\n \\u003cli\\u003eTEE: All cases\\u003c/li\\u003e\\n \\u003c/ul\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd width=\\\"9.375%\\\"\\u003e\\n \\u003cul\\u003e\\n \\u003cli\\u003e53 \\u0026times; 23 mm\\u003c/li\\u003e\\n \\u003cli\\u003e76 \\u0026times; 49 mm\\u003c/li\\u003e\\n \\u003cli\\u003e48 \\u0026times; 25 mm\\u003c/li\\u003e\\n \\u003c/ul\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd width=\\\"19.53125%\\\"\\u003e\\n \\u003cul\\u003e\\n \\u003cli\\u003e3-9 years\\u003c/li\\u003e\\n \\u003cli\\u003eMinor Changes\\u003c/li\\u003e\\n \\u003cli\\u003eRheumatic heart disease: One case\\u003c/li\\u003e\\n \\u003c/ul\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd width=\\\"11.71875%\\\"\\u003e\\n \\u003cp\\u003eGrimaldi \\u003cem\\u003eet al.\\u0026nbsp;\\u003c/em\\u003e(2011)\\u0026nbsp;(24)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd width=\\\"17.96875%\\\"\\u003e\\n \\u003cul\\u003e\\n \\u003cli\\u003eThree\\u003c/li\\u003e\\n \\u003cli\\u003eAge range: 50 to 75 y\\u003c/li\\u003e\\n \\u003cli\\u003eTwo male and one female\\u003c/li\\u003e\\n \\u003c/ul\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd width=\\\"19.53125%\\\"\\u003e\\n \\u003cul\\u003e\\n \\u003cli\\u003eAVR and Bentall procedure for severe AI: One case,\\u003cbr\\u003e\\u0026nbsp;AVR +CGR: One case\\u0026nbsp;\\u003c/li\\u003e\\n \\u003cli\\u003eNone\\u003c/li\\u003e\\n \\u003c/ul\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd width=\\\"21.875%\\\"\\u003e\\n \\u003cul\\u003e\\n \\u003cli\\u003eNone\\u0026nbsp;\\u003c/li\\u003e\\n \\u003cli\\u003eTTE and TEE: All cases\\u003cbr\\u003e\\u0026nbsp;CT-Scan: One case\\u003c/li\\u003e\\n \\u003c/ul\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd width=\\\"9.375%\\\"\\u003e\\n \\u003cul\\u003e\\n \\u003cli\\u003e15 \\u0026times; 20 mm\\u003c/li\\u003e\\n \\u003cli\\u003e15 \\u0026times; 20 mm\\u003c/li\\u003e\\n \\u003cli\\u003e40 \\u0026times; 50 mm\\u003c/li\\u003e\\n \\u003c/ul\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd width=\\\"19.53125%\\\"\\u003e\\n \\u003cul\\u003e\\n \\u003cli\\u003e4 years\\u003c/li\\u003e\\n \\u003cli\\u003eMinor Changes\\u003c/li\\u003e\\n \\u003cli\\u003eNone\\u003c/li\\u003e\\n \\u003c/ul\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd width=\\\"11.71875%\\\"\\u003e\\n \\u003cp\\u003eSalerno \\u003cem\\u003eet al.\\u003c/em\\u003e (2007)\\u0026nbsp;(23)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd width=\\\"17.96875%\\\"\\u003e\\n \\u003cul\\u003e\\n \\u003cli\\u003eOne\\u003c/li\\u003e\\n \\u003cli\\u003e82 y\\u003c/li\\u003e\\n \\u003cli\\u003emale\\u003c/li\\u003e\\n \\u003c/ul\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd width=\\\"19.53125%\\\"\\u003e\\n \\u003cul\\u003e\\n \\u003cli\\u003eImplantation of a biological aortic prosthesis\\u003c/li\\u003e\\n \\u003cli\\u003eNone\\u003c/li\\u003e\\n \\u003c/ul\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd width=\\\"21.875%\\\"\\u003e\\n \\u003cul\\u003e\\n \\u003cli\\u003eFever\\u003c/li\\u003e\\n \\u003cli\\u003eTTE\\u003c/li\\u003e\\n \\u003c/ul\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd width=\\\"9.375%\\\"\\u003e\\n \\u003cp\\u003e62 mm\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd width=\\\"19.53125%\\\"\\u003e\\n \\u003cul\\u003e\\n \\u003cli\\u003e1 year\\u003c/li\\u003e\\n \\u003cli\\u003eMinor Changes\\u003c/li\\u003e\\n \\u003cli\\u003eNone\\u003c/li\\u003e\\n \\u003c/ul\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003c/tbody\\u003e\\n\\u003c/table\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003ey\\u003c/strong\\u003e: years, \\u003cstrong\\u003eTEE\\u003c/strong\\u003e: Transesophageal echocardiography, \\u003cstrong\\u003eTTE\\u003c/strong\\u003e: Transthoracic echocardiogram, \\u003cstrong\\u003eAVR\\u003c/strong\\u003e: Aortic valve replacement, \\u003cstrong\\u003eCABG\\u003c/strong\\u003e: Coronary artery bypass graft, \\u003cstrong\\u003eVSD\\u003c/strong\\u003e: Ventricular septal defect, \\u003cstrong\\u003eCGR\\u003c/strong\\u003e:\\u0026nbsp;Composite graft replacement, \\u003cstrong\\u003emm\\u003c/strong\\u003e: Millimeter, \\u003cstrong\\u003eSAoS:\\u0026nbsp;\\u003c/strong\\u003eSubaortic stenosis, \\u003cstrong\\u003eMRI\\u003c/strong\\u003e: Magnetic resonance imaging, \\u003cstrong\\u003eCT-Scan\\u003c/strong\\u003e: Compound tomography scan, \\u003cstrong\\u003eN/A\\u003c/strong\\u003e: Not available\\u003c/p\\u003e\\n\\u003cp\\u003eImaging and diagnostic tools included TTE for 19 patients, TEE for 21 patients, and MRI and CT scans for 11 patients. These tools were frequently used and mostly showed minor changes in aortic size over the follow-up periods, ranging from 6 months to 30 years. Regarding cardiac complications, most patients did not show any post-procedure complications. However, there was one case of Bechet\\u0026rsquo;s disease, one case of Takayasu, and another with rheumatic heart disease. Furthermore, patients presented with a range of symptoms, including arrhythmias, fever, chest pain, and innocent murmurs. Ten patients presented with moderate and severe aortic regurgitation (AR), while moderate and severe mitral regurgitation (MR) appeared in four cases. Overall, four patients showed signs of both MR and AR\\u0026nbsp;(7, 8, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25).\\u003c/p\\u003e\\n\\u003cp\\u003eWe suggest that more studies and long-term follow-ups of patients with PMAIF who have received non-surgical treatment should be conducted to prove the superiority of the non-surgical method over surgery. Our study was limited by incomplete and/or missing patient records. Additionally, our review was restricted to English literature related to this rare disease entity.\\u003c/p\\u003e\"},{\"header\":\"Conclusion\",\"content\":\"\\u003cp\\u003eBased on our experience with these cases, we propose that surgery is not imperative for asymptomatic patients with PMAIF, even in cases of sizable pseudoaneurysms, as long as there are no further local clinical adverse effects or rapid growth. This conservative methodology is particularly applicable to individuals with a high risk for surgery, for whom regular clinical and echocardiographic monitoring appears to be safe.\\u003c/p\\u003e\"},{\"header\":\"Abbreviations\",\"content\":\"\\u003cp\\u003ePMAIF Pseudoaneurysm of the Mitral-Aortic Intervalvular Fibrosa\\u003c/p\\u003e\\n\\u003cp\\u003eAVR Aortic Valve Replacement\\u003c/p\\u003e\\n\\u003cp\\u003eTTE Transthoracic Echocardiography\\u003c/p\\u003e\\n\\u003cp\\u003eTEE Transesophageal Echocardiography\\u003c/p\\u003e\\n\\u003cp\\u003eEF Ejection Fraction\\u003c/p\\u003e\\n\\u003cp\\u003eAR Aortic Regurgitation\\u003c/p\\u003e\\n\\u003cp\\u003eMR Mitral Regurgitation\\u003c/p\\u003e\\n\\u003cp\\u003eINR International normalized ratio\\u003c/p\\u003e\\n\\u003cp\\u003eCT-Scan Computed tomography scan\\u003c/p\\u003e\\n\\u003cp\\u003emm millimeter \\u003c/p\\u003e\\n\\u003cp\\u003emg milligram\\u003c/p\\u003e\"},{\"header\":\"Declarations\",\"content\":\"\\u003cp\\u003e\\u003cstrong\\u003eStandards of Reporting\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003eA CARE checklist has been provided in Supplementary File 3 for reporting case report studies.\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eEthics approval and consent to participate\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003eThe patient permitted us to use clinical information and photographs to be published.\\u0026nbsp;\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eConsent for publication\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003eSigned written\\u0026nbsp;informed consent was obtained from the patient.\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eAvailability of data and material\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003eData are available based on a request from the corresponding author.\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eCompeting interests\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003eThe authors confirm that there are no known conflicts of interest associated with this publication.\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eFunding\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003eThere has been no significant financial support for this work.\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eAuthors\\u0026apos; contributions\\u0026nbsp;\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003eS.M.M. and F.B. contributed to conceptualizing the study and finalized the manuscript. M.S. and M.R. gathered data and contributed to writing the initial draft. H.Y. and E.F contributed to the visualization of figures performed the literature search and wrote the draft of the search result.\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eAcknowledgments\\u0026nbsp;\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003eWe would like to acknowledge Dr. Taraneh Faghihi Langroudi, M.D., for her review and confirmation of the computed tomography figure.\\u003c/p\\u003e\"},{\"header\":\"References\",\"content\":\"\\u003col\\u003e\\n\\u003cli\\u003eHan J, He Y, Li Z, Chen J, Gu X, Pei J, et al. Pseudoaneurysm of the Mitral‐Aortic Intervalvular Fibrosa in a Patient After Radio Frequency Catheter Ablation of Atrial Fibrillation. Journal of Ultrasound in Medicine. 2009;28(2):249-51.\\u003c/li\\u003e\\n\\u003cli\\u003eTak T. Pseudoaneurysm of mitral-aortic intervalvular fibrosa. Clinical Medicine \\u0026amp; Research. 2003;1(1):49-52.\\u003c/li\\u003e\\n\\u003cli\\u003eChesler E, Mitha AS, Edwards JE. Congenital aneurysms adjacent to the anuli of the aortic and/or mitral valves. Chest. 1982;82(3):334-7.\\u003c/li\\u003e\\n\\u003cli\\u003eTsai I-C, Hsieh S-R, Chern M-S, Huang H-T, Chen M-C, Tsai W-L, et al. Pseudoaneurysm in the left ventricular outflow tract after prosthetic aortic valve implantation: evaluation upon multidetector-row computed tomography. Texas Heart Institute Journal. 2009;36(5):428.\\u003c/li\\u003e\\n\\u003cli\\u003eAgirbasli M, Fadel BM. Pseudoaneurysm of the Mitral‐Aortic Intervavular Fibrosa: A Long‐Term Complication of Infective Endocarditis. Echocardiography. 1999;16(3):253-7.\\u003c/li\\u003e\\n\\u003cli\\u003eSaint‐Martin P, Rogers C, Carpenter E, Fishbein MC, Lau S, Sathyavagiswaran L. Subaortic pseudoaneurysm of the left ventricle complicating staphyloccal endocarditis. Journal of forensic sciences. 2009;54(4):930-2.\\u003c/li\\u003e\\n\\u003cli\\u003eHasin T, Reisner SA, Agmon Y. Large pseudoaneurysms of the mitral-aortic intervalvular fibrosa: long-term natural history without surgery in two patients. Eur J Echocardiogr. 2011;12(3):E24.\\u003c/li\\u003e\\n\\u003cli\\u003eŞahan E, G\\u0026uuml;l M, Şahan S, Sokmen E, Guray YA, Tufek\\u0026ccedil;ioglu O. Pseudoaneurysm of the mitral-aortic intervalvular fibrosa. A new comprehensive review. Herz. 2015;40 Suppl 2:182-9.\\u003c/li\\u003e\\n\\u003cli\\u003eAfridi I, Apostolidou MA, Saad RM, Zoghbi WA. Pseudoaneurysms of the mitral\\u0026mdash;aortic intervalvular fibrosa: Dynamic characterization using transesophageal echocardiographic and Doppler techniques. Journal of the American College of Cardiology. 1995;25(1):137-45.\\u003c/li\\u003e\\n\\u003cli\\u003eCresti A, Baratta P, De Sensi F, Solari M, Sposato B, Minelli S, et al. Normal Values of the Mitral-Aortic Intervalvular Fibrosa Thickness: A Multimodality Study. J Cardiovasc Echogr. 2019;29(3):95-102.\\u003c/li\\u003e\\n\\u003cli\\u003eSudhakar S, Sewani A, Agrawal M, Uretsky BF. Pseudoaneurysm of the mitral-aortic intervalvular fibrosa (MAIVF): A comprehensive review. J Am Soc Echocardiogr. 2010;23(10):1009-18; quiz 112.\\u003c/li\\u003e\\n\\u003cli\\u003eChandra S, Ameta D, Kharwar RB, Goyal M, Kumar D, Dwivedi SK, et al. Three-dimensional echocardiographic delineation of an acquired aorto-left atrial fistula complicating native aortic valve endocarditis - \\u0026quot;advantage of three dimensions\\u0026quot;. Echocardiography. 2013;30(10):E326-30.\\u003c/li\\u003e\\n\\u003cli\\u003eXie M, Li Y, Cheng TO, Wang X, Lu Q, He L, et al. Pseudoaneurysm of the mitral-aortic intervalvular fibrosa. Int J Cardiol. 2013;166(1):2-7.\\u003c/li\\u003e\\n\\u003cli\\u003eRosario Chieppa DR, Scardigno AD, Deluca G, Capodivento S, Quinto N, Cicala M. [Conservative treatment of a pseudoaneurysm of the mitral-aortic intervalvular fibrosa: 9 years of follow-up]. G Ital Cardiol (Rome). 2017;18(6):525-8.\\u003c/li\\u003e\\n\\u003cli\\u003eApostolidou E, Beale C, Poppas A, Stockwell P. Pseudoaneurysm of the Mitral-Aortic Intervalvular Fibrosa: A Case Series with Literature Review. CASE (Phila). 2017;1(6):221-6.\\u003c/li\\u003e\\n\\u003cli\\u003eBishara JA, Dobson C. A 16-Year Natural History of a Congenital Pseudoaneurysm of the Mitral-Aortic Intervalvular Fibrosa. JACC Case Rep. 2022;4(12):706-9.\\u003c/li\\u003e\\n\\u003cli\\u003eCaro-Dominguez P, Gill N, Yoo SJ. MRI evaluation of mitral-aortic intervalvular fibrosa aneurysm in a boy. Cardiol Young. 2017;27(2):402-3.\\u003c/li\\u003e\\n\\u003cli\\u003eDel Pasqua A, Esposito C, Milewski P, Ciliberti P, Chinali M, Secinaro A, et al. Congenital pseudoaneurysm of the mitral-aortic intervalvular fibrosa with a 5 years\\u0026apos; follow up. Int J Cardiovasc Imaging. 2019;35(3):437-8.\\u003c/li\\u003e\\n\\u003cli\\u003eGin A, Hong H, Rosenblatt A, Black M, Ristow B, Popper R. Pseudoaneurysms of the mitral-aortic intervalvular fibrosa: survival without reoperation. Am Heart J. 2011;161(1):130.e1-5.\\u003c/li\\u003e\\n\\u003cli\\u003eHan J, He Y, Gu X, Sun L, Zhao Y, Liu W, et al. Echocardiographic Diagnosis and Outcome of Pseudoaneurysm of the Mitral-Aortic Intervalvular Fibrosa: Results of a Single-Center Experience in Beijing. Medicine (Baltimore). 2016;95(11):e3116.\\u003c/li\\u003e\\n\\u003cli\\u003eLow SCS, Attili A, Bach D, Agarwal PP. CT and MRI features of pseudoaneurysms of the mitral-aortic intervalvular fibrosa. Clin Imaging. 2018;47:74-9.\\u003c/li\\u003e\\n\\u003cli\\u003eNiwano A, Sasaki H, Takaoka H, Yoshida K, Saito K, Suzuki-Eguchi N, et al. Almost Three Decades Conservative Follow-up of Pseudoaneurysm of the Mitral-Aortic Intervalvular Fibrosa Without Radical Surgery. Circ J. 2021;85(12):2247.\\u003c/li\\u003e\\n\\u003cli\\u003eSalerno D, Donati G, Forconi S, Gori T. Giant pseudoaneurysm of the mitro-aortic intervalvular fibrosa: incidental diagnosis. Intern Emerg Med. 2008;3(3):279-82.\\u003c/li\\u003e\\n\\u003cli\\u003eGrimaldi A, Ho SY, Pozzoli A, Sora N, Taramasso M, Benussi S, et al. Pseudoaneurysm of mitral-aortic intervalvular fibrosa. Interact Cardiovasc Thorac Surg. 2011;13(2):142-7.\\u003c/li\\u003e\\n\\u003cli\\u003eBonou M, Papadimitraki ED, Vaina S, Kelepeshis G, Tsakalis K, Alexopoulos N, et al. Mitral-Aortic Intervalvular Fibrosa Pseudoaneurysm. J Cardiovasc Ultrasound. 2015;23(4):257-61.\\u003c/li\\u003e\\n\\u003c/ol\\u003e\"}],\"fulltextSource\":\"\",\"fullText\":\"\",\"funders\":[],\"hasAdminPriorityOnWorkflow\":false,\"hasManuscriptDocX\":true,\"hasOptedInToPreprint\":true,\"hasPassedJournalQc\":\"\",\"hasAnyPriority\":false,\"hideJournal\":false,\"highlight\":\"\",\"institution\":\"\",\"isAcceptedByJournal\":true,\"isAuthorSuppliedPdf\":false,\"isDeskRejected\":\"\",\"isHiddenFromSearch\":false,\"isInQc\":false,\"isInWorkflow\":false,\"isPdf\":false,\"isPdfUpToDate\":true,\"isWithdrawnOrRetracted\":false,\"journal\":{\"display\":true,\"email\":\"info@researchsquare.com\",\"identity\":\"journal-of-cardiothoracic-surgery\",\"isNatureJournal\":false,\"hasQc\":true,\"allowDirectSubmit\":false,\"externalIdentity\":\"jcts\",\"sideBox\":\"Learn more about [Journal of Cardiothoracic Surgery](http://cardiothoracicsurgery.biomedcentral.com)\",\"snPcode\":\"13019\",\"submissionUrl\":\"https://submission.nature.com/new-submission/13019/3\",\"title\":\"Journal of Cardiothoracic Surgery\",\"twitterHandle\":\"@BioMedCentral\",\"acdcEnabled\":true,\"dfaEnabled\":true,\"editorialSystem\":\"em\",\"reportingPortfolio\":\"BMC/SO AJ\",\"inReviewEnabled\":true,\"inReviewRevisionsEnabled\":true},\"keywords\":\"Pseudoaneurysm of the mitral-aortic intervalvular fibrosa, PMAIF, Heart surgery, non-surgical treatment, Case report\",\"lastPublishedDoi\":\"10.21203/rs.3.rs-3964434/v1\",\"lastPublishedDoiUrl\":\"https://doi.org/10.21203/rs.3.rs-3964434/v1\",\"license\":{\"name\":\"CC BY 4.0\",\"url\":\"https://creativecommons.org/licenses/by/4.0/\"},\"manuscriptAbstract\":\"\\u003ch2\\u003eBackground\\u003c/h2\\u003e \\u003cp\\u003eThe pseudoaneurysm of the mitral-aortic intervalvular fibrosa (PMAIF) is a rare complication of endocarditis or aortic valve surgery. Surgical treatment is often suggested, but the possibility of conservative management remains unclear.\\u003c/p\\u003e\\u003ch2\\u003eCase presentation\\u003c/h2\\u003e \\u003cp\\u003eThe 33-year follow-up of a PMAIF that developed six years after aortic valve replacement (AVR) is reported. Initially, the patient began experiencing worsening dyspnea, and echocardiography revealed an ejection fraction (EF) of 20% with a PMAIF measuring 7 \\u0026times; 10 mm. Despite being advised to undergo surgery, the patient declined due to fear of high-risk surgical outcomes. Consequently, conservative treatment with close observation but without surgery was initiated. During the 33-year follow-up period, the patient did not exhibit any adverse health effects.\\u003c/p\\u003e\\u003ch2\\u003eConclusion\\u003c/h2\\u003e \\u003cp\\u003eThe surgery is not necessary for asymptomatic patients with PMAIF, even in cases of sizable pseudoaneurysms, as long as there are no additional local complications or rapid growth. The conservative and non-surgical approach is particularly applicable to patients with a high risk for surgery, for whom regular clinical and echocardiographic monitoring appears to be safe for handling this condition.\\u003c/p\\u003e\",\"manuscriptTitle\":\"Thirty-three years follow-up of pseudoaneurysm of the mitral-aortic intervalvular fibrosa without surgical treatment: case report and literature review\",\"msid\":\"\",\"msnumber\":\"\",\"nonDraftVersions\":[{\"code\":1,\"date\":\"2024-02-21 17:59:14\",\"doi\":\"10.21203/rs.3.rs-3964434/v1\",\"editorialEvents\":[{\"type\":\"communityComments\",\"content\":0},{\"type\":\"decision\",\"content\":\"Revision 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