Ann Thorac Surg 1996;61:737-738
© 1996 The Society of Thoracic Surgeons
Case Report
Right Ventricular Aneurysm Associated With Postinfarction Ventricular Septal Defect
Cesar Nahas, MD,
James W. Jones, MD, PhD,
Javier Lafuente, MD,
Mahesh Ramchandani, MD,
Arthur C. Beall, Jr, MD
Cora and Webb Mading Department of Surgery, Baylor College of Medicine, and Veterans Affairs Medical Center, Houston, Texas
Accepted for publication August 10, 1995.
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Abstract
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Isolated right ventricular aneurysms are rare. Postinfarction right ventricular aneurysm associated with a ventricular septal defect is a very unusual complication. We present such a case that was successfully treated surgically.
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Introduction
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Posterior postinfarction ventricular septal defects are usually associated with variable degrees of necrosis of both the left and right ventricle. The right ventricle is usually more tolerant to ischemia because of its thinner wall and lower intracavitary pressures and possibly because of greater systolic coronary artery flow and a more extensive network of collateral vessels. Although on occasion it has been associated with ventricular arrhythmias or pulmonary emboli, a right ventricular aneurysm if diagnosed is usually asymptomatic and therefore unlikely to warrant a surgical intervention when it is isolated.
A 43-year-old man with a 25-year history of hypertension and a 7-year history of angina suffered an inferior myocardial infarction in May 1992. He did well initially, but began complaining of mild shortness of breath 1 month after his infarction and a new cardiac murmur was noted. A ventricular septal defect was suspected, but the patient refused further investigations. He consented about a year later when his congestive heart failure worsened despite medical treatment. An echocardiogram showed a thin-walled, pulsating mass along the diaphragmatic surface of the right ventricle and communicating with it (Fig 1
). Cardiac catheterization confirmed the left to right shunt with a pulmonary-to-systemic flow ratio of 2.0 and pulmonary artery pressures of 65/35 mm Hg. It showed an occluded dominant right coronary artery with a normal left coronary artery. At operation he was found to have a true aneurysm involving about 50% of the diaphragmatic surface of the right ventricle adjacent to the interventricular septum and without any pericardial adhesions. The aneurysm was opened and its thin wall excised. The ventricular septal defect was easily visualized and measured 1.5 x 1.5 cm (Fig 2). A Dacron patch with interrupted pledgeted sutures on the left ventricular side was used to close the defect. The aneurysmectomy site was repaired with a 5 x 5 cm Dacron patch as well. The left ventricular free wall was grossly normal and uninvolved. The patient made an uneventful recovery.
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Fig 1. . Intraoperative transesophageal echocardiogram showing the right ventricular aneurysm (AN) in relation to the right ventricle (RV) and the left ventricle (LV).
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Fig 2. . Intraoperative photograph showing the ventricular septal defect showing through the opened right ventricular aneurysm. The pledgeted sutures have been placed and passed through the patch.
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Comment
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Right ventricular infarction, once considered rare, occurs in approximately one third of patients with inferior infarctions and is hemodynamically significant in a small percentage of cases. It can be associated with anterior infarctions as well, although in such cases the right ventricular involvement is usually much less extensive. It can be diagnosed using well-accepted electrocardiographic, radionuclide, echocardiographic, and hemodynamic criteria [1]. Isolated right ventricular infarction is rare and is usually associated with total occlusion of a nondominant right coronary artery.
In reviewing heart specimens of patients who died of postinfarction ventricular septal defects, Cummings and associates [2] found that inferiorly located infarctions involved a smaller amount of the left ventricle and a much larger amount of right ventricle than anteriorly located infarcts (31.4% ± 23.6% versus 9.9% ± 8.0%). The right ventricle was affected in all cases of postinfarction ventricular septal rupture. There are many pathophysiologic similarities between postinfarction ventricular septal defects and right ventricular infarction, namely, transmural infarction, involvement of the interventricular septum, impairment of the collateral blood flow to the ischemic region, and acute coronary arterial occlusion. It is unusual, however, to have only minimal to no involvement of the left ventricle.
There is a paucity of reports on right ventricular aneurysms in the literature. In contrast to left ventricular aneurysms, which develop as a sequel of myocardial infarction in the vast majority of the cases, right ventricular aneurysms are rare and are usually secondary to trauma or surgical procedures involving the right ventricle [3, 4]. They can also be congenital, inflammatory, or associated with ventricular arrhythmias [5]. Very few cases of true isolated right ventricular aneurysm after right ventricular infarction have been reported [6], and coronary artery disease is rarely implicated in the pathogenesis. Using radionuclide scans, Incalzi and associates [7] reported 11 right ventricular aneurysms diagnosed out of 137 consecutive cases of acute myocardial infarction. This finding had a very negative impact on survival. Right ventricular rupture is also rarely reported and is caused by a serpiginous hemorrhagic tract that courses through the infarct [8].
Sauerbruch, in 1931, excising what was presumed to be a mediastinal tumor, inadvertently entered the sac of a right ventricular aneurysm and successfully repaired it. Several successful repairs using cardiopulmonary bypass followed Stansel and colleagues' report in 1963 [4], and 1 patient had an associated posttraumatic ventricular septal defect as well [3].
Since the first report by Cooley in 1957 of successful repair of postinfarction ventricular septal defect, many advances have improved the prognosis. The contributions of Daggett to the management of this problem are invaluable. His principles of approaching the defect through a wide infarctectomy of the left ventricle, of conservative debridement of the right ventricle, and of closure without tension using prosthetic materials are well accepted. The negative impact of preoperative right ventricular dysfunction as a result of a right ventricular infarction on early mortality and long-term survival in cases of acute septal rupture is well recognized. It appears, however, that when the left ventricle is minimally involved, especially when the presentation is late, the prognosis is excellent.
In this unusual case the left ventricular free wall was essentially normal and therefore the defect was approached through the right side. The increased right-sided pressures secondary to the septal defect probably played a significant role in the development of the aneurysm in the infarcted, thinned area.
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Footnotes
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Address reprint requests to Dr Nahas, Surgical Service (112), Houston VAMC, 2002 Holcombe Blvd, Houston, TX 77030.
Address reprint requests to Dr Sakakibara, Department of Surgery (I), Kanazawa University School of Medicine, 13-1 Takaramachi, Kanazawa 920, Japan.
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References
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- Setaro JK, Cabin HS. Right ventricular infarction. Cardiol Clin 1992;10:69–90.[Medline]
- Cummings RG, Reimer KA, Califf R, Hackel D, Boswick J, Lowe JE. Quantitative analysis of right and left ventricular infarction in the presence of postinfarction ventricular septal defect. Circulation 1988;77:33–42.[Abstract/Free Full Text]
- Stinson EB, Rowles DF, Shumway NE. Repair of right ventricular aneurysm and ventricular septal defect caused by nonpenetrating cardiac trauma. Surgery 1968;64:1022–6.[Medline]
- Stansel HC Jr, Julian OC, Dye WS. Right ventricular aneurysm. A review of the literature and report of a case of successful repair with the aid of temporary cardiopulmonary bypass. J Thorac Cardiovasc Surg 1963;46:66–76.[Medline]
- Lyons CJ, Scheiss WA, Johnson LW, Parker FB Jr. Surgical treatment of right ventricular aneurysm: an uncommon procedure. Ann Thorac Surg 1977;23:221–4.[Abstract]
- Andersen HR, Falk E. Isolated right ventricular aneurysm following right ventricular infarction. Cardiology 1987;74: 479–82.[Medline]
- Incalzi RA, Capparella O, Gemma A, Puglielli L, Bonetti MG, Carbonin P. Right ventricular aneurysm: a new prognostic indicator after a first acute myocardial infarction. Cardiology 1991;79:120–6.[Medline]
- Schieman G, Wolf P, Podolin R, Haghighi P, Maisel AS. Rupture of the ventricular septum and right ventricle complicating myocardial infarction. Am Heart J 1988;116:560–2.[Medline]
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Abstract
Introduction
