Ann Thorac Surg 2001;71:2020-2022
© 2001 The Society of Thoracic Surgeons
Case report
Mitral valve replacement and endocavitary patch repair for a giant left ventricular pseudoaneurysm
Andras Kollar, MD, PhDa,
Benjamin F. Byrd, III, MDb,
Henry K. Lui, MDc,
Davis C. Drinkwater, Jr, MDb
a Department of Cardiac and Thoracic Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA
b Division of Cardiology, Vanderbilt University Medical Center, Nashville, Tennessee, USA
c University of Tennessee, Jackson-Madison County General Hospital, Jackson, Tennessee, USA
Accepted for publication April 19, 2000.
Address reprint requests to Dr Drinkwater, Department of Cardiac and Thoracic Surgery, 2986 The Vanderbilt Clinic, Nashville, TN 37232
e-mail: davis.drinkwater{at}surgery.mc.vanderbilt.edu
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Abstract
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We present a case of a giant inferior left ventricular (LV) wall pseudoaneurysm. The patient had New York Heart Association class IV heart failure due to severe mitral valve regurgitation and poor LV function. Our operative approach included right thoracotomy, excision of the mitral valve, and patch repair of the pseudoaneurysm neck from inside of the dilated LV cavity followed by mitral valve replacement. Surgery was performed without aortic cross-clamping on a normothermic perfused beating heart. The patient had an uncomplicated cardiac recovery and is doing well 15 months after surgery.
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Introduction
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Left ventricular (LV) pseudoaneurysm, or "false" aneurysm, is defined as a contained perforation of the myocardium [1, 2]. It is a rare clinical entity, most often associated with myocardial infarction, and has a higher propensity for rapid enlargement and rupture than true aneurysms [3, 4]. For this reason, resection of the sac and primary or patch repair of the aneurysmal neck is recommended [4–6]. In this article, we present a case of a giant pseudoaneurysm of the inferior left ventricular wall and describe a successful operative approach for aneurysm repair and mitral valve replacement.
A 75-year-old man presented who had two previous coronary artery bypass grafting (CABG) procedures 10 and 12 years before presentation. Two years after his second operation, he developed symptoms of fatigue and dyspnea, and cardiac catheterization demonstrated a small inferior pseudoaneurysm. At that time, he was treated medically. In subsequent years, however, he developed worsening chronic heart failure.
In September 1998, he underwent cardiac catheterization again for progressive symptoms. This showed occlusion of his native coronary arteries, an occluded right coronary artery graft, widely patent retrosternal left internal mammary artery, patent circumflex graft, and no potential target vessels in the distal right coronary artery tree. His LV injection revealed a giant inferior false aneurysm (Fig 1) and significant mitral regurgitation. He also had severe pulmonary hypertension, chronic obstructive pulmonary disease, history of stroke, and bleeding peptic ulcer disease. Transesophageal echocardiography (TEE) confirmed a giant thrombus-filled pseudoaneurysm with a large (6 x 6-cm) neck and 3+ mitral regurgitation. The pseudoaneurysm extended to the mitral valve annulus postero-inferiorly (Fig 2). His LV was dilated with an estimated ejection fraction (EF) of 15%. His case was turned down for surgery in two different institutions.
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Fig 2. Transesophageal echocardiographic view of the pseudoaneurysm neck (PsA) and its association to the left ventricle (LV) and left atrium (LA). (Ao = aorta.)
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We felt that surgery was indicated, but taking into account his poor LV function and multiple comorbidities, a conventional redo sternotomy appeared to be prohibitive in his case. We therefore modified our surgical plan and approached the heart via right thoracotomy with the plan to patch the pseudoaneurysm neck from inside the LV cavity.
The operation was done under general anesthesia with a double-lumen endotracheal intubation. We inserted an intraaortic balloon pump (IABP) via the left groin under TEE control. While the patient’s chest was opened in the fifth intercostal space, right groin vessels were exposed for femoro-femoral cannulation. On left lung ventilation, the pericardium was opened anterior to the phrenic nerve, and the right atrium, superior vena cava (SVC), and Waterston’s groove were dissected free together with the right and anterosuperior surface of the ascending aorta. No attempt was made to localize any of the coronary grafts. No dissection was done posteriorly or around the inferior vena cava. The patient was heparinized and cardiopulmonary bypass was instituted adding an SVC cannula and an active aortic vent to the circuit. The patient was kept normothermic, and the heart was perfused and allowed to beat without cross-clamping the aorta.
The left atrium was opened anterior to the pulmonary veins and the mitral annulus was exposed. The incompetent mitral valve was excised, and via the dilated mitral annulus, the large thrombus-filled pseudoaneurysm was readily identified. The chronic pseudoaneurysm neck was well demarcated and strong enough to hold sutures. Interrupted pledgeted 2-0 Tevdek sutures were placed (Fig 3) alongside the pseudoaneurysm neck (pledgets excluded from the LV cavity), and an appropriate size Gore-Tex cardiovascular patch was inserted to cover the defect. Posteriorly, the patch was used to reinforce the mitral valve annulus, and a 29-mm Edwards porcine valve (model 6625; Baxter, Irvine, CA) was easily implanted with interrupted pledgeted 2-0 Tevdek sutures. An LV vent was placed across the valve and the left atrial incision was closed. Meticulous deairing was performed through the LV vent and also the aortic suction vent under TEE control before the heart was allowed to fully eject again. The patient was weaned off bypass on IABP support, adding moderate inotropic support.
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Fig 3. Schematic illustration of our surgical approach: the mitral valve is excised and the pseudoaneurysm neck was patched from inside the LV cavity.
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Postoperatively, the patient remained stable, his IABP was removed on the second day, and he was extubated on postoperative day 4. One week after the operation, a repeat TEE showed a clot-filled, excluded pseudoaneurysm with only trivial patch leak (Fig 4), and an ejection fraction of 20% to 30%. Twelve months later, his functional status is NYHA I–II, and a repeat transthoracic echocardiogram did not identify a patch leak.
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Fig 4. Postoperative TEE (identical view with Fig 2). See the echodense valvular structure in the mitral annulus and a patch underneath (arrow). Abbreviations are as in Figure 2.
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Comment
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Postinfarction pseudoaneurysms are typically localized on the inferior segment of the left ventricular wall [2, 5, 6]. While an aneurysm has unrestricted continuity with the LV cavity, pseudoaneurysms have a well-defined neck representing the original perforation. The causes of mitral regurgitation in cases of LV false aneurysm are papillary muscle rupture, chordal fibrosis, or LV dilatation.
The principle of surgical repair is straightforward. Once the neck of the false aneurysm is dissected out, the perforation can be closed primarily or with patch repair. It is important, however, to avoid manipulation and dissection around the false aneurysm minimizing the risk of bleeding and embolization [5]. Surgical mortality is around 10% to 15% [2, 5, 6]. Concomitant mitral valve replacement increases mortality significantly. In the literature, we found five reported cases of false aneurysm resection combined with mitral valve replacement [4, 5]. Four patients died within 1 week after surgery and 1 patient in the Toronto experience [5] survived for 2 months. It was postulated that the presence of significant mitral regurgitation represents more extensive myocardial damage, involving a larger area of the LV wall as well as the right heart, rendering survival less likely. Based on the published results, mitral valve replacement in these patients appears to be an almost prohibitive surgical risk.
In our case, we wished to avoid a redo sternotomy as well as dissection around the false aneurysm if possible. Having reviewed the preoperative TEE, it was felt that mitral valve replacement was unavoidable. Approaching the heart through a right thoracotomy and removing the mitral valve first, we were looking into the dilated LV cavity and were able to identify the large neck of the false aneurysm from inside. This way, we could avoid taking down adhesions around the heart, preventing the possibility of external bleeding from the LV aneurysm or suture line. The small residual patch leak noted 1 week postoperatively was, in fact, into the old contained cavity that had become almost completely thrombosed.
This case was further complicated by the fact that we elected not to dissect out the left internal mammary artery graft and therefore could not arrest the heart. Normothermic continuous perfusion with a beating heart appeared the best option to preserve function and was technically tolerable due to our beating heart coronary bypass experience.
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References
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Buehler D.L., Stinson E.B., Oyer P.E., Shumway N.E. Surgical treatment of aneurysms of the inferior left ventricular wall. J Thorac Cardiovasc Surg 1979;78:74-78.[Abstract]
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Abstract
Introduction
