Surgical Treatment of Left Ventricular Pseudoaneurysm
CASE REPORT
doi: 10.5455/medarh.2014.68.215-217 Med Arh. 2014 Jun; 68(3): 215-217
Published online: 31/05/2014 Published print: 06/2014
Received: March 14th 2014 | Accepted: May 25th 2014 © AVICENA 2014
Surgical Treatment of Left Ventricular Pseudoaneurysm Emir Mujanovic1, Jacob Bergsland1,2, Sevleta Avdic1, Sanja Stanimirovic-Mujanovic1, Tamara Kovacevic-Preradovic3, Emir Kabil1 BH Heart Center Tuzla, Tuzla, Bosnia and Herzegovina1 The Intervention Centre, Oslo University Hospital, Oslo Norway2 3 may remain silentand unless it gives Clinic for cardiovascular diseases, Clinical Center Banja Luka, Bosnia Herzegovina
rise to hemopericardium, once the hemoperica
develops, it may in cardiac andHerzegovina, sudden death Corresponding author: prof Emir Mujanovic, MD, PhD. BH Heart Centerresult Tuzla, Alekse Santica 8,tamponade Tuzla, Bosnia and Phone: (6). 035 309 140, 035 309 149, Email:
[email protected]
Because
aneurysms have a strong tendency to rupture, this disorder may lead to death if it i
ABSTRACT
surgically untreated (7).
Introduction: Left ventricular pseudoaneurysm is a rare condition because in most instances ventricular free-wall rupture leads to fatal In this caseisreport, we present a patient who underwent pericardial tamponade. Rupture of the free wall of the left ventricle a catastrophic complication of myocardial infarction,successful occurring repair of a in approximately 4% of patients with infarcts, resulting in immediate collapse of theinfarction patient andthat electromechanical In rare which followed a myocardial was caused dissociation. by occlusion of the left circu cases the rupture is contained by pericardial and fibrous tissue, and the result is a pseudoaneurysm. The left ventricular pseudoaneurysm coronary artery. contains only pericardial and fibrous elements in its wall-no myocardial tissue. Because such aneurysms have a strong tendency to rupture, this disorder may lead to death if it is left surgically untreated. Case report: In this case report, we present a patient who underwent successful repair of a left ventricular pseudoaneurysm, which followed a myocardial infarction that was caused by occlusion of the left circumflex coronary artery. Although repair of left ventricular pseudoaneurysm is still a surgical challenge, it can be performed with acceptable results in most patients. 2. PATIENT AND METHOD Key words: left ventricular pseudoaneurysm, surgical repair.
1. INTRODUCTION
A 57-year-old male patient wasMETHOD admitted to another hospital with chest pain 2. PATIENT AND
Left ventricular pseudoaneurysm (LVP) a very 7rare A 57-year-old male patient angiography, was admittedselective to another hadisstarted days previously. During coronary left coronary inj condition because in most instances ventricular free-wall hospital with chest pain that had started 7 days previouswith(1). showed occlusion of the coronary distal leftangiography, circumflex artery.(Figure 1). The ventriclograp rupture leads to fatal pericardial tamponade Myocarly. During selective left coronary dial infarction (MI) is the most common cause an- 2,injection with showed occlusiontoofbe theandistal left circumshownofinfalse Figure demonstrating what appeaers aneurysm. eurysms of the left ventricle (2, 3). Rupture of the free wall flex artery.(Figure 1). The ventriculography is shown in of the left ventricle is most often catastrophic complica- Figure 2, demonstrating what appears to be an aneurysm. tion of MI, occurring in approximately 4% of patients with infarcts resulting in immediate collapse of the patient (4). In addition, it may be associated with mitral valve replacement, previous unsuccessful ventriculotomy, trauma, inflammation, tumor invasion, and apical venting (5). LVP develop when pericardium surrounds the rupture in combination with thrombus and inflammation and thus prevents the development of a hemopericardium. It contains only pericardial and fibrous elements in its wall, with no myocardial tissue. LVP may remain silent unless it gives rise to hemopericardium, once the hemopericardium develops, it may result in cardiac tamponade and sudden death (6). Because such aneurysms have a strong tendency to rupture, this disorder may lead to death if it is left surgically untreated (7). In this case report, we present a patient who underwent successful repair of a LVP, which followed a myocardial infarction that was caused by occlusion of the left circumFigure 1. Coronary angiography: occlusion of the left circumflex flex coronary artery. artery in its distal portions
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Figure 1. Coronary angiography: occlusion of the left circumflex artery in its distal por
Figure 4. Intraoperative finding: opened left ventricular pseudoaneurysm Surgical Treatment of Left Ventricular Pseudoaneurysm
Figure 5.Figure Rapair 5. of defect dacronwith patchdacron patch Rapairwith of defect
Figure 2. Ventriculography: left ventricular pseudoaneurysm in the inferobasalwas wall.resected, and the defect in the inferior wall of the left Figure 2. Ventriculography: left ventricular pseudoaneurysmThe in postoperative course was uneventful. An echocardiogram on the third ventricle repaired with a Dacron patch (Figure 5). the inferobasal wall. postoperative day showed improvement in ejection fraction to 0.50, and the repair site was Theand postoperative course was uneventful. An echocarEchocardiography showed LV dysfunction with an ejection fraction of 0.35 seen (Figure 6). on There a minimal mitral regurgitation. the 6-months followEchocardiography showed LV dysfunction withclearly an ejecdiogram thewas third postoperative day showedAt improveureakinesia 2. Ventriculography: leftthis ventricular pseudoaneurysm in the had inferobasal wall. of the inferor wall. On echo it became that the patient a large tion fraction of 0.35 and akinesia ofappearent the inferior wall. On ment in ejection up visit, the patient was in NYHAfraction Class I. to 0.50, and the repair site was LVP measuring cm on apparent the inferobasal communicating through clearly a narrowseen (Figure 6). There was a minimal mitral regurthisarround echo it5x5 became that wall, the patient had a large
LVP measuring around neck of 2,2 cm in diameter (Figure 3). 5x5 cm on the inferobasal wall,
gitation. At the 6-months follow-up visit, the patient was
Echocardiography showedthrough LV dysfunction of Class 0.35 I.and communicating a narrow neckwith of 2,2an cmejection in diam- fraction in NYHA
eter (Figure 3). ia of the inferor wall. On this echo it became appearent that the patient had a large
measuring arround 5x5 cm on the inferobasal wall, communicating through a narrow
f 2,2 cm in diameter (Figure 3).
Intraoperatively, a large nonruptured pseudoaneurysm Figure 3. Echocardiography: large posterior left ventricular pseudoaneu-was seen to Figure 3. Echocardiography: large left ventricular pseudoaneurysm in the in the inferobasal wall measured 2x3 cm in diameter. It was located communicate rysm through a the neck which inferobasal wall Figure 6. Postoperative echocardiography after pseudoaneurysm Figure 6. Postoperative echocardiography after pseudoaneurysm repair Intraoperatively, a large non pseubeneath the posterior papillary muscle (Figure 4).ruptured The LVP posterior was resected, and therepair defect in
doaneurysm was seen to communicate through a the neck which measured 2x3 cm in diameter. It was located be- 3. DISCUSSION neath the posterior papillary muscle (Figure 4). 3.The LVP LVP is rare with a prevalence of 0.05% (8), and usually DISCUSION develops in patients having their first MI (9). Inferior and posterolateral MI are responsible for 82% of the LVP deLVP isveloping rare withafter a prevalence of 0.05% and usualy develops in patients having MI. Usually, LVP(8), is located inferoposterior occlusion of the circumflex but itfor can82% be of the LVP their first MIdue (9).toInferior and posterolateral MI areartery, responsible found in the apical region due to anterior MI. Anterior MI Figure 3. Echocardiography: large left ventricular pseudoaneurysm in the developing after MI. Usualy, LVP is located inferoposteriorly due to occlusion of the rarely results in LVP formation because ruptures in the inferobasal wall circumflex artery, but itwall can generally be found in the apical region due to anterior MI. Anterior MI anterior leads to hemopericardium or tam11). LVP mayruptures remaininclinically silent and be rarely results ponade in LVP (10, formation because the anterior wall generally leads to discovered during routine clinical investigations, or can hemopericardium or tamponade (10,11). LVP may remain clinically silent and be present with chest pain, congestive heart failure, arrhythdiscovered during clinical investigations, or can present withfailure chest pain, mias,routine or embolism. The development of heart is congestive heart failure, related arrhythmias, embolism. The development of heart failure is related to an to anornon contracted and dyskinetic region, with dilatation of the pseudoaneurysm sac during systole. Fatal uncontracted and dyskinetic region, with dilatation of the pseudoaneurysm sac during rupture, hemopericardium, and tamponade are importsystole. Fatal rupture, hemopericardium, and tamponade are important complications of ant complications of pseudoaneurysm. The risk of acute Figure 4. Intraoperative finding: opened left ventricular pseudo- complications is higher in the first 3 months after MI. LVP Figure 4. Intraoperative finding: opened left ventricular pseudoaneurysmare associated with a mortality rate approaching 50%. This aneurysm
the inferior wall of the left ventricle repaired with a dacron patch (Figure 5).
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Med Arh. 2014 Jun; 68(3): 215-217
Surgical Treatment of Left Ventricular Pseudoaneurysm
is mainly due to rupture, thromboembolism or ventricular arrhythmia (12). Cardiac catheterization with left ventriculography has been the gold standard for establishing the diagnosis, and is necessary before surgery to evaluate the need for concomitant bypass grafting (13). In addition, Echocardiography is an alternative imaging modality (14). There is strong indication for surgery in LVP (15) since untreated pseudoaneurysm have a 30% to 45% risk of rupture (16). The general consensus is that surgery is indicated for all patients as soon as the diagnosis is established, unless the surgical risk is prohibitive. If a pseudoaneurysm is diagnosed within 2 to 3 months after MI, emergency surgery should be performed because of the high risk of rupture. If the diagnosis is made years after MI, the necessity and urgency of surgery depends on the symptoms. LVPs smaller than 3 cm detected incidentally, may be managed conservatively. Resection, if necessary, combined with bypass grafting is the treatment of choice in symptomatic patients, but the operative risk is high due (7%–29%) to the underlying cardiac pathologies (17). CONFLICT OF INTEREST: NONE DECLARED
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