Ann Thorac Surg 1997;63:1472-1473
© 1997 The Society of Thoracic Surgeons
Case Report
Recurrent Left Ventricular False Aneurysm
Michael W. Stanton, MD,
Mark B. Douthit, MD,
Ronald D. Jenkins, MD,
Matthew R. Holland, MD,
Stephen L. Martin, MD,
Misa A. Albreht, MD
Boulder Community Hospital, Boulder, Colorado
Accepted for publication December 11, 1996.
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Abstract
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A recurrent left ventricular false aneurysm 5 years after patch repair and causing progressive congestive heart failure was readily diagnosed by echocardiography and heart catheterization. Its substrate was suture dehiscence of undetermined origin. Urgent repair was successful. The long-term prognosis is guarded.
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Introduction
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A postinfarction left ventricular pseudoaneurysm (LVPA) is an infrequent condition [1, 2]. We describe its late recurrence due to a patch suture dehiscence.
Five years after LVPA repair, a 77-year-old man was admitted on May 17, 1996, for a 3-week history of congestive heart failure without chest pain or fever. On examination, he was severely dyspneic, with a sinus tachycardia of 110 beats/min, blood pressure 120/70 mm Hg, an apical 4/6 pansystolic murmur, and peripheral edema. Laboratory tests showed normal cardiac enzymes, a normal white blood cell count, and respiratory acidosis. The electrocardiogram showed an old inferior wall infarction with left bundle-branch block. Echocardiography revealed a large LVPA with pseudocontrast with bidirectional color flow through a narrow neck (Fig 1
). The left ventricle (LV) was dilated with an akinetic, thin inferior wall, a hypokinetic lateral wall, and mild mitral regurgitation. Heart catheterization revealed a cardiac index of 2.1 L•sec-1•m-2, LV pressure of 116/21 mm Hg, pulmonary capillary wedge pressure of 19 mm Hg, and pulmonary artery pressure of 82/26 mm Hg. Coronary angiography showed severe three-vessel native occlusive disease, normal appearance of all three previously placed bypass grafts with good distal run-off (left internal mammary artery to left anterior descending artery, vein graft to right coronary artery, and vein graft to the obtuse marginal artery), and a new 75% stenosis of a large ramus intermedius. Left ventricular ejection fraction was 0.30. An 8 x 14-cm inferior LVPA and mild mitral regurgitation were seen.
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Fig 1. . Preoperative transthoracic echocardiographic apical image demonstrating the large pseudoaneurysm. The arrow defines its neck. (LA = left atrium; LV = left ventricle; RA = right atrium; RV = right ventricle.)
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The past history was significant for hypertension and an inferior wall myocardial infarction in 1987. In 1991 he underwent resection of a 10 x 10-cm inferior LVPA with a patch repair of a 4 x 6-cm wall defect and three-vessel coronary artery bypass grafting. Histologic evaluation showed extensive fibrosis, mild chronic inflammation, mural thrombus, and no myocardial elements. Since 1994 he has been on chronic hemodialysis for end-stage renal disease. Late in 1994, an episode of transient congestive heart failure without signs of a new infarction prompted echocardiography, which showed a dilated LV, LV ejection fraction of 0.37, mild mitral regurgitation, and inferior wall akinesis but no pericardial effusion and no signs of LVPA. Over the ensuing 18 months he did reasonably well, although he required multiple hospital admissions for a transient ischemic attack, a vascular access operation, pelvic fractures on two separate occasions, and mild head trauma sustained in an automobile accident 3 weeks before his current admission.
An urgent reoperation on May 20, 1996, disclosed a 20-mm suture dehiscence of a Dacron patch used in 1991 without signs of infection. On direct smear, no organisms were seen, and tissue culture at 7 days had no growth. Thinned myocardium adjacent to the patch dehiscence appeared necrotic. A heavily scarred 10 x 10-cm sac inferior to the heart and partially filled with thrombus communicated with the LV via the patch dehiscence. The thinned ventricular wall surrounding the patch prompted its removal and subsequent repair with a new patch (Hemashield; Meadox Medical, Inc, Oakland, NJ). Both papillary muscles appeared intact. Previous bypass grafts were free of disease, and all had satisfactory velocity profiles on Doppler imaging. The ramus intermedius was revascularized. The aortic cross-clamp time was 15 minutes with a cardiopulmonary bypass time of 209 minutes. Bleeding was significant in spite of aprotinin use. The postoperative course was notable for stable hemodynamics, respiratory insufficiency, and a slow recovery. At 3-month follow-up, the patient was free of overt heart failure and echocardiography demonstrated persistent LV dysfunction with resolution of the LVPA (Fig 2).
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Fig 2. . Postoperative transthoracic echocardiographic image demonstrating resolution of pseudoaneurysm. (LA = left atrium; LV = left ventricle; P = patch; RV = right ventricle.)
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Comment
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Operation for recurrent LVPA is rare, without mention in a recent review [1] or the largest single institutional LVPA repair series [2]. Extension of infarction adjacent to the site of a true aneurysm [3], reinfarction distal to an occluded coronary artery bypass graft [3, 4], progression of coronary atherosclerosis [4], early [5] and late [6] breakdown of primary closure, and suture dehiscence due to infection [7, 8] have all been implicated as causes.
In our case, the cause of the recurrent LVPA could have been either an undisclosed reinfarction or a disruption of the intact suture and patch from the scar. Infection was excluded. We cannot determine the timing of the patch dehiscence but feel certain it was absent in 1994 as documented by echocardiography. Later there were no clinical signs to suggest recurrent cardiac rupture until the time of the minor head trauma several weeks before this admission. Except for the lack of chest pain, the clinical presentation, echocardiogram, and angiogram of the recurrent LVPA corresponded closely to LVPA cases reported elsewhere [1--3]. This repair was done on normothermic bypass without application of an aortic cross-clamp, in contrast to techniques reported elsewhere [2]. This approach works well in patients without aortic regurgitation because it eliminates ischemic injury and allows tailoring of the patch to maintain a more normal geometry of the ventricle. The heart was elevated on a laparotomy pad and decompressed via a left atrial sump. The defect edges were debrided and reinforced with felt bolsters inside and out before suture application of the patch. Although the early result in our case has been satisfactory, the long-term prognosis is guarded due to his ischemic cardiomyopathy.
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Acknowledgments
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We acknowledge the assistance of Ms Vicki Collins, RDCS, and Ms Jane Tokar in preparation of the manuscript.
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Footnotes
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Address reprint requests to Dr Stanton, North Colorado Heart & Lung Clinic, PLLC, 1800 Fifteenth St, Suite 340, Greeley, CO 80631.
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References
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- Pomini G, Lupisa M, Milano A, Gribaldo R. Pseudoaneurisma del ventricolo sinistro: descrizione di due casi. G Ital Cardiol 1993;23:289–92.[Medline]
- Adkins MS, Glenn WL, Pollock SB, Fernandez J, McGrath LB. Left ventricular pseudoaneurysm with hemoptysis. Ann Thorac Surg 1991;51:476–8.[Abstract]
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- Pitlik S, Cohen L, Melamed R, Rosenfeld J. Mural endocarditis associated with recurrent false aneurysm of the left ventricle. Chest 1977;71:227–9.[Abstract]
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Abstract
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