Ann Thorac Surg 1999;68:252-254
© 1999 The Society of Thoracic Surgeons
Case Reports
Repeat syncopal attacks due to postsurgical right ventricular pseudoaneurysm
Raffaele Calabrò, MDa,
Giuseppe Santoro, MDa,
Carlo Pisacane, MDa,
Giuseppe Pacileo, MDa,
Maria Giovanna Russo, MDa,
Carlo Vosa, MDb
a Department of Pediatric Cardiology, II University of Naples, "V. Monaldi" Hospital Naples, Naples, Italy
b Department of Cardiac Surgery, II University of Naples, "V. Monaldi" Hospital, Naples, Italy
Address reprint requests to Dr Calabrò, Department of Pediatric Cardiology, "V. Monaldi" Hospital, Via Bracco, 71, Naples 80131, Italy
e-mail: mocarped{at}tin.it
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Abstract
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Pseudoaneurysm of the right ventricular outflow tract is a rare lesion caused by disruption of the ventricular wall that allows the blood to leak into the surrounding space. It often complicates surgery involving right ventriculotomy and progressively increases in size, therefore causing airway compression, pulmonary perfusion asymmetry, thromboembolism, and rupture. We report on a patient who developed right ventricular pseudoaneurysm early after surgery for atrio-ventricular septal defect with tetralogy of Fallot and needed emergency surgical repair due to low cardiac output and repeat syncopal attacks.
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Introduction
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Pseudoaneurysm of the right ventricular outflow tract (RVOT) is an exceedingly rare lesion that may complicate myocardial infarction, endomyocardial biopsy, or, more commonly, surgical procedures involving right ventriculotomy and placement of outflow patch, conduit, or homograft [1–7]. It is usually caused by a small disruption of the right ventricular (RV) wall that allows the blood to leak into the surrounding space because its walls are made up of fibrin and pericardium and contain no myocardial elements [8]. A pseudoaneurysm progressively increases in size and may cause airway compression, left-to-right pulmonary perfusion asymmetry, thromboembolism, and rupture [7, 8], while clinical presentation with syncopal attack is very unusual. We report on a patient who developed RV pseudoaneurysm early after surgery for atrio-ventricular septal defect with tetralogy of Fallot and needed emergency surgical repair due to low cardiac output and repeat syncopal attacks.
A 14-year-old patient affected by Down’s syndrome and complete atrio-ventricular septal defect with tetralogy of Fallot underwent surgical repair with double-patch technique and RVOT enlargement with a Gore-Tex patch, resulting in a postoperative RV/left ventricular (LV) ratio of 0.4. One month after discharge, he was again hospitalized due to fever and repeat syncopal attacks. At clinical examination, a systolic ejective murmur at the RVOT level and RV failure signs were evident. Chest roentgenogram showed mild cardiac enlargement and normal pulmonary markings. At electrocardiogram, sinus rhythm with normal atrio-ventricular conduction and complete right bundle branch block were recorded. Two-dimensional echocardiography showed a large echo-free space severely compressing the RVOT (Fig 1A) and partially filled by a large thrombus (Fig 1B). With color Doppler analysis, a to-and-fro flow between the RV body and the cavity (Fig 1C) through a small ventricular wall discontinuity was clearly recorded, prompting us to make the diagnosis of pseudoaneurysm obstruction of the RVOT. This diagnosis was confirmed by transesophageal echocardiography and cardiac catheterization (Fig 2), with a peak-to-peak pressure gradient across the RVOT of 75 mm Hg and an RV/LV ratio of 1.0. Thus, the patient underwent emergency surgical repair. At operative field, the ventricular wall discontinuity, due to the suture breakdown at the lower margin of patch implant, was confirmed and successfully treated by pseudoaneurysm resection and RVOT reconstruction. Finally, the patient was successfully discharged on the 10th postoperative day.
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Fig 1. (A and B) Cross-sectional parasternal short-axis view of the RV outflow tract showing an echo-free space (Pan), containing a large thrombotic mass (CLOT), that markedly compresses the RV outflow tract. (C) Systolic color Doppler image showing a low-velocity flow (red-colored signal) passing from the right ventricular outflow tract to the pseudoaneurysmal cavity through a discontinuity of the ventricular wall (arrow); the RV outflow tract obstruction is clearly imaged as a high-velocity turbulent flow passing to the pulmonary artery (yellow-blue mosaic signal). RA, right atrium; RV, right ventricle; AO, aorta; PA, pulmonary artery; Pan, pseudoaneurysm; asterisks, neck of the pseudoaneurysm.
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Fig 2. RV angiography in right anterior oblique view showing the pseudoaneurysmal cavity (asterisks) that fills during the ventricular ejection period, so compressing the right ventricular outflow tract. RA, right atrium; RV, right ventricle; MPA, main pulmonary artery; RPA, right pulmonary artery; LPA, left pulmonary artery.
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Comment
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Pseudoaneurysm is a rare spontaneous or iatrogenic complication of the RV pathology. It may be due to RV infarction, endovascular procedures, or, more commonly, right ventriculotomy with placement of outflow patch, conduit, or homograft [1–7]. Regardless of etiology, pseudoaneurysm arises from a small ventricular rupture that allows the blood to leak into the surrounding space, resulting in a pericardial-contained hematoma. The tendency for pseudoaneurysms to progressively enlarge and then spontaneously rupture has been clearly demonstrated [8]. Clinically, RV pseudoaneurysms may be either diagnosed during routine follow-up examination or become symptomatic due to mediastinal mass effect, thromboembolism, or rupture [7, 8]. Due to the slow enlargement of the compressing mass, symptoms progressively get worse, while an acute, dramatic, and life-threatening clinical presentation is very unusual. Unlike all previously reported cases, our patient presented with right ventricular failure and low cardiac output signs as well as repeat, increasingly frequent syncopal attacks, presumably due to a progressive compressing effect of the pseudoaneurysmal mass, possibly influenced by intrathoracic pressure changes. Thus, an immediate diagnosis and emergency surgery was required. The presence of a thrombus inside the compressing echo-free space, as well as the blood flow through its neck, led us to strongly suspect the diagnosis of RV pseudoaneurysm and send the patient to a successful surgical treatment.
In conclusion, pseudoaneurysm is a rare but life-threatening complication of the surgical relief of RVOT obstructions. It should always be suspected and sought in patients submitted for right ventriculotomy, particularly if they show symptoms of either mediastinal compression or low cardiac output. In most cases, echocardiography could reliably diagnose the location and size of the pseudoaneurysm and its neck, therefore avoiding any invasive diagnostic approach.
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Acknowledgments
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This work was supported by grants from the Programma Operativo del Piano "Cardiopatie Congenite Critiche Neonatali (CCCN)" #B006 of the Ministero dell’ Università e Ricerca Scientifica (MURST), and the European Community (no. 711/1998).
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References
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Rodriguez A.C., de Vylder A., Wellens F., Bartunek J., De Bruyne B. Right ventricular pseudoaneurysm as a complication of endomyocardial biopsy after heart transplantation. Chest 1995;107:566-567.[Abstract/Free Full Text]
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Payne W.S., Kirklin J.W. Late complications after plastic reconstruction of outflow tract in tetralogy of Fallot. Ann Surg 1961;154:53-57.
-
Moore W.S., Hall A.D. Late suture failure in the pathogenesis of anastomotic false aneurysms. Ann Surg 1970;172:1064-1070.[Medline]
-
Manga P., King J. Trauma-induced pseudoaneurysm of the right ventricle. Am J Cardiol 1985;55:1658-1659.[Medline]
-
Wheller J.J., Teske D.W., Craenen J.M., Allen H.D. Right ventric-ular pseudoaneurysm following repair of tetralogy of Fallot. Am Heart J 1990;119:1207-1209.[Medline]
-
Sadiq M., Fenton A.C., Firmin R.K. False aneurysm of the right ventricular outflow tract after total correction of tetralogy of Fallot. Br Heart J 1994;71:566-568.[Abstract/Free Full Text]
-
Levine J.C., Mayer J.E., Keane J.F., Spevack P.J., Sanders S.P. Anastomotic pseudoaneurysm of the ventricle after homograft placement in children. Ann Thorac Surg 1995;59:60-66.[Abstract/Free Full Text]
-
Vladover Z., Coe V.I., Edwards J.E. True and false left ventricular aneurysm. Propensity for the latter to rupture. Circulation 1975;51:567-572.[Abstract/Free Full Text]
Accepted for publication December 21, 1998.
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Abstract
Introduction
