Ann Thorac Surg 2000;70:275-276
© 2000 The Society of Thoracic Surgeons
Case report
Surgical treatment of a chest-wall penetrating left ventricular pseudoaneurysm
Matthias Bauer, MDa,
Michele Musci, MDa,
Miralem Pasic, MD, PhDa,
Friedrich Knollmann, MDa,
Roland Hetzer, MD, PhDa
a Department of Cardiothoracic and Vascular Surgery, Deutsches Herzzentrum, Berlin, Germany
Address reprint requests to Dr Bauer, Department of Cardiothoracic and Vascular Surgery, Deutsches Herzzentrum Berlin, Augustenburger Platz 1, 13353 Berlin, Germany
e-mail: mbauer{at}dhzb.de
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Abstract
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This report describes the treatment of a patient who developed a chest-wall penetrating pseudoaneurysm 3 years after coronary bypass grafting and after the resection of a lateral wall left ventricular aneurysm twice. The patient presented with a pulsatile tumor in the left submammilar region. Surgery was done in deep hypothermia, with femoro-femoral cannulation and via a left anterolateral thoracotomy. The perioperative course was uneventful and the patient is still well 5 years after surgery.
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Introduction
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The development of a pseudoaneurysm is a rare event after the resection of a left ventricular aneurysm. In this case, resection of a lateral wall left ventricular aneurysm was done twice prior to the development of the pseudoaneurysm. The pseudoaneurysm was extraordinary in size and extended under the skin of the lateral chest wall. There is only one similar case known in the literature [1]. We describe our surgical technique.
The first manifestation of coronary heart disease in a 66-year-old male was myocardial infarction in 1977. After developing a lateral wall left ventricular aneurysm, he underwent an aneurysmectomy and aortocoronary bypass at another institution in 1988 and reaneurysmectomy in 1991. The patient presented at our institution in 1994 with a pulsating protrusion and redness in the area of the left lateral thoracic wall below the mammilla. He was in New York Heart Association class III.
Chest x-rays showed the heart to be pathologically enlarged, primarily to the left, and exhibiting an aberrant contour (Fig 1). Cardiac catheterization, echocardiography, and computer tomography (Fig 2) revealed a laterally and apically situated pseudoaneurysm with a narrow connection between the left ventricle and the aneurysm, which perforated the thoracic wall.
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Fig 2. Computed tomography scan of the chest showing a large left ventricular pseudoaneurysm, which has perforated the chest wall.
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The operation was done with femoro-femoral bypass, deep hypothermic cardiac arrest (18°C) with low-flow perfusion (1.5 l/min) through a left anterolateral thoracotomy. The wall of the false aneurysm was prepared and the aneurysmal sack opened. The 2 x 2 cm connection between the left ventricle and the false aneurysm was closed with several deeply seated 3-0 Prolene U-patch sutures. De-airation was achieved through the ventricular wall defect before complete closure. A drainage conduit was placed in the pseudoaneurysmal cavity. Under a moderate dose of catecholamine, the patient was weaned from extracorporeal circulation. The postoperative course was uncomplicated.
We reevaluated the patient 5 years after surgery. He was in good general condition without any signs of heart insufficiency (New York Heart Association class II). He had a normal configuration of the heart on computed tomography scan (Fig 3) and echocardiography. Left ventricular ejection fraction was 30%.
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Comment
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This case report describes a rare complication after the resection of left ventricular aneurysms with the Cooley method [2]. Aneurysms situated on the lateral wall of the left ventricle are also a rare condition [3].
Pseudoaneurysms may occur after myocardial infarction, cardiac surgery, eg, mitral valve replacement, infections, or after trauma [4, 5]. In our case, the pseudoaneurysm obviously developed through partial suture dehiscence after aneurysm resection. The first successful surgical treatment of a ventricular pseudoaneurysm was described by Sauerbruch in 1931. It was a right ventricular pseudoaneurysm which was opened under the assumption that it was a mediastinal cyst [6].
Rao and colleagues [1] reported in 1998 about a 62-year-old man who developed a pseudoaneurysm of the left ventricle with subcutaneous herniation 14 years after left ventricular aneurysmectomy. The operation was undertaken with aortoatriocaval cardiopulmonary bypass, moderate systemic hypothermia, and antegrade cold-blood cardioplegic arrest. In our case, because of the two previous operations and the spread of the pseudoaneurysm under the skin of the lateral chest wall, we performed the operation with femoro-femoral cardiopulmonary bypass with deep hypothermia, low-flow perfusion, and approached the heart through a left anterolateral thoracotomy.
The surgical treatment of pseudoaneurysms depend upon their origin, size, and local extension. In the case of previous heart operations and lateral or apical situated pseudoaneurysms of great dimension, an operation in deep hypothermic cardiac arrest, with low-flow perfusion, through a lateral thoracotomy that avoids resternotomy, is highly recommended.
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Acknowledgments
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We are grateful for editorial assistance from Tonie Derwent.
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References
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Rao M.S., Vaijyanath P., Taneja K., Dubey B., Manchanda S.C., Venugopal P. Recurrent pseudoaneurysm of the left ventricle with subcutaneous herniation into the chest wall. Tex Heart Inst J 1998;25:309-311.[Medline]
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Cooley D.A., Henly W.S., Amad K.H., Chapman D.W. Ventricular aneurysm following myocardial infarction. Ann Surg 1959;150:595-612.[Medline]
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Ruvolo G., Greco E., Speziale G., Di Natale M., Marino B. Surgical repair of pseudo-aneurysm arising from a true chronic aneurysm of the left ventricular lateral wall. Eur J Cardiothorac Surg 1994;8:449-450.[Abstract]
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Maselli D., Micalizzi E., Pizio R., Audo A., De Gasperis C. Posttraumatic left ventricular pseudoaneurysm due to intramyocardial dissecting hematoma. Ann Thorac Surg 1997;64:830-831.[Abstract/Free Full Text]
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Frances C., Romero A., Grady D. Left ventricular pseudoaneurysm. J Am Coll Cardiol 1998;32:557-561.[Abstract/Free Full Text]
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Sauerbruch F. Successful surgical correction of an aneurysm of the right cardiac chamber. Arch Klin Chir 1931;167:586-588.
Accepted for publication November 23, 1999.
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