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Ann Thorac Surg 2002;73:1303-1305
© 2002 The Society of Thoracic Surgeons

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Case report

Left ventricular pseudoaneurysm late after mitral valve replacement

^a Division of Cardiothoracic Surgery, The Ohio State University, Columbus, Ohio, USA

Accepted for publication August 17, 2001.

* Address reprint requests to Dr Ono, Department of Cardiothoracic Surgery, University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo 113-8655, Japan
e-mail: ono-tho{at}h.u-tokyo.ac.jp

	Abstract

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We report an unusual case of left ventricular pseudoaneurysm late after mitral valve replacement. A 60-year-old woman, who had undergone aortic and mitral valve replacement using mechanical prostheses 4 months previously, presented with severe congestive heart failure. The computed tomographic scan of the chest demonstrated a large mass displacing the heart anteriorly. The orifice of the pseudoaneurysm was successfully closed on the beating heart using partial femorofemoral bypass through a left thoracotomy.

	Introduction

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Rupture of the left ventricular posterior wall is a serious complication after mitral valve replacement (MVR). It is traditionally classified into three types according to the timing of the presentation: early, delayed, or late. Early rupture is an event that occurs in the operating room any time after termination of cardiopulmonary bypass. Delayed rupture refers to an instance occurring hours to several days after transfer to the intensive care unit. Late rupture is an event seen days to years after MVR, presenting with the development of left ventricular pseudoaneurysm (LVPA). Left ventricular pseudoaneurysm may develop after myocardial infarction, trauma, infective endocarditis, and heart operation. Karlson and colleagues [1] reviewed 125 collected cases of rupture of left ventricular posterior wall after MVR, in which late rupture presenting as an LVPA was seen only in 12 cases (9.9%). We report a successful surgical treatment in a patient with the largest LVPA ever reported on the beating heart through a left thoracotomy.

A 60-year-old female patient was transferred with the diagnosis of LVPA. The patient had undergone replacement of aortic and mitral valves using 21-mm and 27-mm prostheses (Carbomedics, Austin, TX) at an outside hospital 4 months previously. The mitral valve was severely stenotic, fibrosed, and thickened. The posterior leaflet was excised preserving the posterior chordae. Soon after transfer to the intensive care unit the chest was reexplored for massive bleeding, which was caused by rupture of the left ventricular posterior wall. The rupture site was repaired from the epicardial side with pledgeted sutures. She eventually was discharged. Fourteen weeks after the operation, the patient was readmitted with severe congestive heart failure. Computed tomographic scan of the chest demonstrated a 13-cm x 9-cm x 7-cm mass adjacent to the heart, which displaced the heart anteriorly against the chest wall (Fig 1).

View larger version (140K): [in this window] [in a new window]   Fig 1. Computed tomographic scan of the chest showing a large left ventricular pseudoaneurysm (arrows).

The fifth intercostal space was opened. Femorofemoral bypass was initiated. Under transesophageal echocardiography guidance we palpated the aneurysmal wall, and observed the tear of the left ventricle. The LVPA was incised anterior and parallel to the phrenic nerve. There were a large amount of organized thrombi and a moderate amount of fresh clot in the outer layer. The site of rupture was identified easily just below the posterior left atrioventricular groove. It was 1 cm in length. The rupture site was completely closed with four 2-0 pledgeted sutures on the beating heart, taking great care not to pass deeply with the sutures to avoid injury to the coronary sinus and the left circumflex coronary artery. The patient was weaned from cardiopulmonary bypass easily (bypass time, 63 minutes). The operation was completed uneventfully in 210 minutes. The patient was extubated on the next day. Postoperative transesophageal echocardiography revealed no residual leak from the repaired site. The patient was discharged from the hospital 7 days after the operation. She was not taking diuretics and was living an active life at a 4-month follow-up visit.

	Comment

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Left ventricular pseudoaneurysm was reported to occur in 0.8% of cases after MVR [2]. The causative factors are similar to those of rupture of the left ventricular posterior wall seen early after MVR. The differences between these pathogeneses can be summarized in two points: the timing of the rupture—early or late onset after MVR—and the status of rupture—free or contained. The most important condition required for the formation of LVPA is the existence of conditions leading to contained rupture. Treasure and associates [3] proposed that the confluence of three factors might be required to produce an early rupture of the left ventricular posterior wall after MVR. These are predisposition by an underlying myocardial weakness, inadvertent or aggressive surgical manipulations that produce the primary tear, and dynamic forces that prompt the development of transmural rupture. Minimal damage to the annulus, the endomyocardium, or the epicardium, or partial thickness disruption of the left ventricle [4], which does not lead to a transmural disruption at the time of MVR, may finally cause a full-thickness rupture late after operation to develop into an LVPA.

The clinical features of LVPA are similar to those of mitral regurgitation. Congestive heart failure and shortness of breath are the most common symptoms [5]. Pansystolic murmur, which is derived from the leaking of blood into an LVPA, is audible in some of the patients with LVPA. Differentiation from paravalvular leak and prosthetic valve dysfunction is necessary. When the size of the LVPA is small, the patient may be asymptomatic. An LVPA may present as a bulge along the left heart border on chest roentgenogram. A dome-shaped or fistula-like extravasation along the posterolateral wall of the left ventricle is seen by left ventriculography. Doppler or color flow-mapping echocardiography demonstrates blood flow across the orifice of the LVPA [6]. Computed tomographic scan with contrast medium is very helpful for better understanding the spatial relationship of the LVPA to the cardiac chambers and the chest wall, particularly for a large LVPA.

Surgical repair of LVPA was performed either from inside of the left atrium or from the epicardial surface without opening the cardiac chambers. An internal repair has advantages: (1) better exposure of the subannular apparatus is obtained to make the repair straightforward; (2) additional cardiac abnormalities can be repaired simultaneously; and (3) the left circumflex coronary artery is better protected than with an external repair. Its disadvantage is that the mitral prosthesis may need to be explanted for exposure and repair of a rupture site in most cases even though the prosthesis is functioning normally. Also, longer myocardial ischemic time may be required than with an external repair. If there is neither some other intracardiac disease nor prosthetic mitral valve dysfunction, an external repair may be chosen. However, extensive adhesion lysis is usually required for this type of repair when approached by a repeated median sternotomy. A left thoracotomy may provide better access to an LVPA in selected cases. The risks entailed by repeat median sternotomy can be avoided. Minimal adhesiolysis is required, and the duration of cardiopulmonary bypass can be shortened. Presentation of the lesion by retracting the heart is avoided by the left thoracotomy approach. The epicardial tissue around a tear is considered thick and strong enough to hold the sutures late after MVR. Careful sutures on the posterior left atrioventricular groove can avoid damage to the left circumflex coronary artery or the coronary sinus.

In conclusion, a left thoracotomy approach was very effective to treat the LVPA late after MVR. Examination by both transesophageal echocardiography and computed tomographic scan was useful to obtain correct diagnosis and decide a surgical plan.

	References

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1. Karlson K.J., Ashraf M.M., Berger R.L. Rupture of left ventricle following mitral valve replacement. Ann Thorac Surg 1988;46:590-597.[Abstract]
2. Sakai K., Nakamura K., Ishizuka N., Nakazawa M., Hosoda S. Echocardiographic findings and clinical features of left ventricular pseudoaneurysm after mitral valve replacement. Am Heart J 1992;124:975-982.[Medline]
3. Treasure R.L., Rainer W.G., Strevey T.E., Sadler T.R. Intraoperative left ventricular rupture associated with mitral valve replacement. Chest 1974;66:511-514.[Abstract/Free Full Text]
4. Cobb B.W., Hatcher C.R., Craver J.M., Jones E.L., Sewell C.W. Transverse midventricular disruption after mitral valve replacement. Am Heart J 1980;99:33-50.[Medline]
5. Sharratt G.P., Ross J.K., Monro J.L., Johnson A.M. Intraoperative left ventricular perforation with false aneurysm formation. Br Heart J 1976;38:1154-1159.[Abstract/Free Full Text]
6. Roelandt J., Sutherland G.R., Yoshida K., et al. Improved diagnosis and characterization of left ventricular pseudoaneurysm by Doppler color flow imaging. J Am Coll Cardiol 1988;12:807-811.[Abstract]

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This Article Abstract Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Randall K. Wolf Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Ono, M. Articles by Wolf, R. K. Search for Related Content PubMed PubMed Citation Articles by Ono, M. Articles by Wolf, R. K. Related Collections Valve disease