Ann Thorac Surg 1995;60:438-440
© 1995 The Society of Thoracic Surgeons
Case Reports
Surgical Management of Ventricular Tachycardia in Subannular Left Ventricular Aneurysm
Louis F. Janeira, MD,
Uzi Talit, MD,
Robert Parker, MD,
Carolyn E. Hughes, MD,
Ishik C. Tuna, MD
Departments of Medicine and Surgery, Saint Mary's Medical Center, Evansville, Indiana, and the Indiana University School of Medicine, Evansville, Indiana
Accepted for publication January 19, 1995.
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Abstract
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Submitral left ventricular aneurysms typically affect young adults of African ancestryAu: OK as in text?. These aneurysms are characterized by heart failure and mitral insufficiency, and occur in the absence of coronary disease. We report a rare case of symptomatic ventricular tachycardia in association with submitral left ventricular aneurysm (and no mitral insufficiency). Ventricular tachycardia was abolished by aneurysm resection and ventricular reconstruction. We suggest surgical management is indicated for ventricular tachycardia associated with this unusual condition, and may be curative.
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Introduction
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Submitral left ventricular aneurysm is an unusual condition of obscure origin, typically affecting young adults of African ancestry [1, 2]. This condition is characterized by aneurysms occurring adjacent to the mitral annulus in the absence of coronary disease [3]. Progressive heart failure is common, and results from mitral insufficiency secondary to severe distortion of the mitral valve apparatus. Plication of the aneurysm and repair of the valve is recommended under these circumstances [4].
Rarely, there have been reports of patients with submitral left ventricular aneurysms presenting solely with symptomatic ventricular tachycardia [5–7]. We present such a case, and discuss its management and surgical cure.
A 33-year-old Nigerian woman presented to the hospital with near-syncope and sustained monomorphic ventricular tachycardia. She was treated with lidocaine and procainamide, terminating her tachycardia and symptoms. She gave no history of previous cardiac disease and had been in good health. There was no family history of sudden death.
A chest radiograph revealed a calcified mass adjacent to the cardiac silhouette. A transthoracic echocardiogram demonstrated a submitral left ventricular aneurysm. The aneurysm orifice extended from beneath the posterior mitral valve leaflet to the base of the papillary muscles. No mitral insufficiency was present, and no additional abnormalities were present. Cardiac catheterization confirmed these findings and demonstrated absence of coronary disease (Fig 1
). Cardiac electrophysiologic evaluation revealed easily inducible, sustained monomorphic ventricular tachycardia, with a morphology identical to her clinical tachycardia.
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Fig 1. . Coronary arteriogram demonstrating the calcified aneurysm and lack of occlusive disease in the coronary arteries. The right coronary artery was similarly free of disease.
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Propafenone was administered, abolishing her tachycardia, and rendering her noninducible during electrophysiologic testing. Intolerable side effects of propafenone developed, and administration of the drug was discontinued. Frequent episodes of sustained monomorphic ventricular tachycardia recurred, and resection of the aneurysm was proposed.
At operation, a 5- by 6-cm aneurysm was identified, involving the diaphragmatic surface of the left ventricle (Fig 2A). This aneurysm was bordered by the left atrioventricular groove, the posterior descending coronary artery, and the terminal branch of the circumflex coronary artery. The epicardium overlying the aneurysm was thickened and discolored (white). The aneurysm was resected through an epicardial approach (Fig 2B). The coronary arteries, papillary muscle, chordae, and posterior mitral leaflet were preserved. Friable thrombus was present within the aneurysm. Endocardial fibrosis adjacent to the orifice of the aneurysm involved the base of the papillary muscle and the mitral annulus, and was fulgurated. The ventricular defect was repaired using a Dacron patch. After discontinuation of cardiopulmonary bypass, transesophageal echocardiography demonstrated normal mitral valve function.
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Fig 2. . (A) Intraoperative appearance of the aneurysm. The apex of the heart is elevated cephalad to expose the diaphragmatic surface of the right (R) and left (L) ventricles. The epicardium overlying the aneurysm is discolored (white). The aneurysm extends from the base (B) of the left ventricle 5 to 6 cm toward the apex, and is bounded laterally by the posterior descending coronary artery, and the terminal branch of the circumflex coronary artery (not seen). (B) Intraoperative appearance after resection of the aneurysm. The apex (A) of the heart is retracted cephalad, exposing the posterior mitral valve leaflet, chordae, and papillary muscles. The posterior descending coronary artery has been preserved.
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Postoperatively, ventricular tachycardia was absent. One week after operation, ventricular tachycardia could not be induced during electrophysiologic testing. The patient has remained free of cardiovascular symptoms for 18 months off all medications.
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Comment
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In excess of 100 cases of subannular left ventricular aneurysm have been reported since Corvisart's description in 1812 [3]. The reports of Chesler [1] and Abrahams [2] and their colleagues provide comprehensive descriptions of the major clinical features of this disorder, consisting of severe congestive heart failure, mitral insufficiency, and rapid progression to death. Subsequent reports describe the occurrence of such aneurysms adjacent to the aortic valve, and in a variety of additional ethnic groups [3]. Plication of the aneurysm and repair of the insufficient valve has been advocated as the treatment of choice for congestive heart failure associated with this disorder [4].
Symptomatic ventricular tachycardia is among the least common features of this condition and rarely has been reported. In 4 prior cases, all patients were young adults of African ancestry, and all presented with palpitations or near syncope, in the absence of heart failure or mitral insufficiency [5–7]. One patient died, one was managed medically, and no follow-up was provided in the remainder.
The present case is unusual in several regards. In this unusual setting, surgical intervention was demonstrated to be useful in the management of ventricular tachycardia. The efficacy of this approach was verified by electrophysiologic testing, and freedom from clinical events during 18 months of follow-up. Furthermore, the operative technique differs significantly from that advocated by Antunes [4] (aneurysm plication and valve reconstruction through a transatrial approach), for the management of the most common complication of subannular aneurysm, heart failure, and mitral insufficiency.
In summary, submitral left ventricular aneurysms may result in symptomatic ventricular tachycardia in the absence of coronary disease. This case report documents the surgical technique (identical to that used in atherosclerotic aneurysms) and efficacy of aneurysm resection in this setting. Alternate management options would include medical therapy, defibrillator implantation, or radiofrequency ablation. In this young group of patients, issues such as drug intolerance, compliance, implantable cardioverter defibrillator generator replacement, embolization from intracavitary thrombus, and the unknown potential for future mitral valve dysfunction secondary to subannular aneurysm, would appear to favor operative management as we have described.
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Footnotes
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Address reprint requests to Dr Tuna, 350 W Columbia St, Evansville, IN 47710.
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References
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- Chesler E, Joffe N, Schamroth L, Meyers A. Annular subvalvular left ventricular aneurysms in the South African Bantu. Circulation 1965;32:43–51.[Abstract/Free Full Text]
- Abrahams DG, Barton CJ, Cockshott WP, Edington GM, Weaver EJM. Annular subvalvular left ventricular aneurysms. Q J Med 1962;31:345–60.
- Head HD, Jue KL, Askren CC. Aortic subannular ventricular aneurysms. Ann Thorac Surg 1993;55:1268–72.[Abstract]
- Antunes MJ. Submitral left ventricular aneurysms: correction by a new transatrial approach. J Thorac Cardiovasc Surg 1987:94:241–5.[Abstract]
- Chesler E, Dubb A, Tim LO. Ventricular tachycardia due to subvalvular left ventricular aneurysms. S Afr Med J 1967;7:518–21.
- Okuwobi BO. Multiple ventricular aneurysms. Am J Cardiol 1975;35:521–3.
- Fitchett DH, Kanji M. Mitral subannular left ventricular aneurysm: a case presenting with ventricular tachycardia. Br Heart J 1983;50:594–6.[Abstract/Free Full Text]
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Abstract
Introduction
