Ann Thorac Surg 1998;66:2102-2104
© 1998 The Society of Thoracic Surgeons
Case Reports
Left ventricular pseudoaneurysm after epicardial patch electrode placement
William H. Maisel, MDa,
Jeanne M. Lukanich, MDb,
Raphael Bueno, MDb,
Peter L. Friedman, MD, PhDa,
Sharon C. Reimold, MDa
a Cardiovascular Division, Department of Medicine, Brigham and Women’s Hospital, Boston, Massachusetts USA
b Division of Thoracic Surgery, Department of Surgery, Brigham and Women’s Hospital, Boston, Massachusetts, USA
Accepted for publication May 28, 1998.
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Abstract
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There are many known complications of implantable cardioverter-defibrillator placement. We treated a patient in whom a left ventricular pseudoaneurysm developed secondary to epicardial patch electrode placement and cardioverter-defibrillator implantation. The presenting symptoms, diagnostic evaluation, and surgical repair are described.
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Introduction
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Since 1980, over 35,000 patients have had implantable cardioveter-defibrillators (ICD) implanted with epicardial patch electrodes to prevent sudden death [1]. Complications of ICDs include lead fracture, early generator failure, discharges for nonventricular rhythms, failure to terminate ventricular arrhythmias, infection, bleeding or thrombosis, coronary artery erosion, and pericardial constriction [1,2]. We describe the case of a left ventricular pseudoaneurysm complicating epicardial ICD patch electrode placement.
A 65-year-old woman presented with acute onset hemoptysis. Four years before admission she had a witnessed cardiac arrest and underwent ICD placement after coronary angiography demonstrated no significant obstructive coronary disease and electrophysiology studies revealed no inducible arrhythmia. Transvenous lead placement was complicated by right ventricular perforation. Thoracotomy was performed with drainage of a small hemorrhagic pericardial effusion, repair of a 1-cm anterior right ventricular perforation, and extrapericardial patch electrode placement in anterior and posterolateral positions.
The patient was well until several days before admission. She developed intermittent hemoptysis with production of several cups of red blood. Chest roentgenogram demonstrated a left lower lung field process with documented change in the cardiac silhouette from 1 year previously (Fig 1). Computed tomographic scan of the thorax revealed an irregular, homogeneous fluid collection posterolateral to the heart and in close proximity to the posterolateral ICD patch (Fig 2). A transesophageal echocardiogram was performed; it demonstrated flow between the left ventricle and extracardiac fluid collection, suggesting the diagnosis of pseudoaneurysm (Fig 3).
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Fig 1. Chest roentgenograms 1 year before admission (A) and at presentation (B) are shown. Note the change in cardiac silhouette (white arrows) and the fluid level in the left lung field (dark arrows).
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Fig 2. Chest computed tomographic scan shows an epicardial patch electrode (arrow) and a fluid density subsequently diagnosed as a pseudoaneurysm (PA).
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Fig 3. Transesophageal echocardiogram shows an irregular posterolateral epicardial patch electrode (EE) and posterolateral fluid collection. Pulsatile Doppler flow at 2.5 m/s could be demonstrated between the left ventricle (LV) and the fluid collection confirming the presence of a pseudoaneurysm (PA).
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The patient underwent biplane left ventriculography, which demonstrated a small irregularity of the posterolateral left ventricular contour but no definite evidence of pseudoaneurysm. Pulmonary angiography did not demonstrate a source of hemoptysis. The patient underwent thoracotomy, which revealed a 1-cm hole in the posterolateral left ventricle at the site of the patch electrode with communication into a pseudoaneurysm. Primary left ventricular repair with pledgeted sutures and pulmonary wedge resection were performed after removal of the epicardial patch. The patient tolerated the procedure well, and before discharge she received a new transvenous lead system for her ICD without complication.
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Comment
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Left ventricular pseudoaneurysms occur as the result of ventricular free wall rupture in the presence of an adherent pericardium or fibrous tissue. Most commonly they result from ventricular rupture after myocardial infarction, although they can also occur after cardiac operation, trauma, endocarditis, myocardial biopsy, and ablation of accessory pathways [3].
Free rupture of the left ventricle usually has catastrophic consequences. In a minority of patients, pseudoaneurysms could form. In the present case, both an adherent pericardium and an ICD patch might have favored pseudoaneurysm formation rather than frank rupture. Although echocardiography, magnetic resonance imaging, and nuclear imaging can often confirm the diagnosis of left ventricular pseudoaneurysm, left ventriculography has been described as the diagnostic procedure of choice [4]. Left ventriculography was falsely negative in this case, likely because of intermittent flow into the pseudoaneurysm. Patients with a negative left ventriculogram, but a high clinical suspicion for pseudoaneurysm should undergo further diagnostic testing.
Hemoptysis is an extremely rare presenting symptom of ventricular pseudoaneurysm. It usually results from ventriculopulmonary fistula formation and has been described in patients with infected pseudoaneurysms and, as in this patient, those with previous cardiac operation [5]. Because pseudoaneurysms have a propensity to rupture, surgical repair has been uniformly recommended, although survival without repair for months to years after diagnosis has been reported [6].
Although most ICD systems are now placed transvenously, many patients have had epicardial systems implanted. Ventricular pseudoaneurysms are a rare complication of epicardial ICD patch electrode placement. The diagnosis should be considered in patients with epicardial patches who present with intermittent or massive hemoptysis or with abnormal fluid collection around the heart.
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References
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Abstract
Introduction
