Ann Thorac Surg 2004;77:1813-1815
© 2004 The Society of Thoracic Surgeons
Case report
Delayed rupture of a postinfarction left ventricular true aneurysm
Sinan Arsana*,
Serdar Akgunc,
Muhsin Turkmend,
Nuri Kurtoglub,
Tekin Yildirima
a Departments of Cardiovascular Surgery, Marmara University School of Medicine, Istanbul, Turkey
b Departments of Cardiology, Maltepe University School of Medicine, Istanbul, Turkey
c Department of Cardiovascular Surgery, Marmara University School of Medicine, Istanbul, Turkey
d Department of Cardiology, Kosuyolu Heart and Research Hospital, Istanbul, Turkey
Accepted for publication June 3, 2003.
* Address reprint requests to Dr Arsan, Maltepe Üniversitesi Tip Fakültesi, Ataturk Cad. Cam Sok. No: 3/A, Maltepe, 81530 Istanbul, Turkey
e-mail: arsans{at}ixir.com
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Abstract
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Delayed rupture of a true left ventricular aneurysm is a rare clinical condition. We report a case of a 60-year-old woman who underwent emergency surgical repair of a ruptured true aneurysm of the left ventricular inferior wall 3 months after the myocardial infarction. The repair consisted of endoaneurysmorraphy patch technique. The patient made a satisfactory recovery.
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Introduction
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Left ventricular aneurysm (LVA) is a common complication of myocardial infarction. The most common type of aneurysm is a true aneurysm, which forms after transmural infarction by gradual thinning and expanding of the scarred left ventricular wall. The rupture of a true LVA is very rare and generally has a fatal outcome [1, 2]. In rare instances, an adherent thrombus or pericardial adhesion may seal a ventricular rupture and this permits survival of the case. Contained rupture may result in formation of a false aneurysm, the outer walls of which are formed by the pericardium and mural thrombus. We report a case of a delayed ruptured true aneurysm of the left ventricular inferior wall, 3 months after the myocardial infarction, and successful surgical repair.
The patient was a 60-year-old woman who was admitted to our hospital with chest pain. Acute inferior myocardial infarction (MI) was diagnosed and she was given intravenous heparin. Coronary angiography and left ventriculography showed inferior left ventricular true aneurysm (Fig 1)
with total right coronary artery occlusion with a poor distal run-off. She was discharged with a decision of a medical treatment. She was doing well with an antianginal medication and had only a few nonspecific symptoms.
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Fig 1. True aneurysm of the left ventricular inferior wall. The arrows indicate a true aneurysm on the inferior left ventricular wall.
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She was readmitted to our hospital because of severe congestive heart failure developing and gradually worsening in a week. Transthoracic echocardiography revealed a rupture of the left ventricular true aneurysm. The patient was transferred to catheterization laboratory for cardiac catheterization, coronary angiography, and left ventriculography 3 months after the onset of myocardial infarction. Left ventriculography revealed that there was a rupture of the previously detected true aneurysm of the left ventricular wall and leaking into the pericardial cavity (Fig 2). Therefore, the prompt decision for surgery was made.
The cardiopulmonary bypass was established between the ascending aorta and the right atrium. A large hemopericardium was evacuated. Once the aneurysmal complex (6 x 7 cm) was opened it was confirmed to be a ruptured large inferior true aneurysm.
It contained a large amount of old thrombi and communicated with the left ventricle through a wide single orifice in the inferior left ventricular wall. The opening was intimately associated with the base of both papillary muscles and the mitral valve annulus without ventricular septal defect. The rupture was then securely repaired by using an endoventricular circular patch plasty technique [3].
The patient tolerated the procedure very well and was weaned from cardiopulmonary bypass easily with minimal inotropic support. She was discharged home on the sixth postoperative day. The control left ventriculogram 3 months after the operation showed a satisfactory result (Fig 3).
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Comment
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The diagnosis of the LVA may be suspected by the clinical finding of a diffuse, pansystolic apical thrust, persistent segment elevation (ST) on the electrocardiogram, and distortion of the cardiac silhouette on chest roentgenogram after acute myocardial infarction. The definitive diagnosis is achieved by transthoracic and transesophageal echocardiography, angiography, or magnetic resonance imaging [4]. The rupture of the left ventricle after myocardial infarction occurs more commonly than expected. With increasing awareness of this complication in the face of suggestive clinical features and availability of diagnostic tools, more patients must be referred for surgical repair.
The clinical presentation may be heralded by an acute hemodynamic decompensation in most patients. Circulatory arrest and death rapidly follow rupture if blood is freely ejected into the pericardial cavity. Survival is possible only if an obstruction and an adherent thrombus or pericardial adhesion exists. In this rare condition blood infiltrates the myocardium, causing a delayed subacute rupture.
Left ventricular true aneurysm rupture is not a well-defined and recognized complication of myocardial infarction and generally causes fatal outcome. Left ventricular free wall rupture is responsible for 12% of 21% of deaths after myocardial infarctions [5]. Most LV free wall ruptures occur within 2 weeks after infarction; the peak incidence was at 5 days [1].
The period between the formation of the LV aneurysm and the rupture may be varied, and prolonged up to months long. Sakai and colleagues reported a patient with a ruptured true left ventricular aneurysm 49 days after the onset of MI [4]. Another patient with a delayed rupture of true left ventricular aneurysm was reported by Raudkivi and colleagues [6]. It was a rupture of a calcified left ventricular aneurysm 10 years after initial infarction.
In the present case, true aneurysm of the left ventricular wall can be clearly seen in the ventriculogram, performed 10 days after the onset of acute myocardial infarction. Rupture occurred 3 months after the onset of myocardial infarction.
Surgical treatment of ventricular rupture has varied over time and is often individualized, depending on the state of the tear and the presence of concomitant lesions. The standard repair involves an infarctectomy including the area of rupture, and reconstructing the ventricle with a patch of polytetrafluoroethylene (Teflon) or Dacron sutured directly to the myocardium with cardiopulmonary bypass.
We perform concomitant coronary artery bypass grafting only if the coronary anatomy is known and feasible. We believe strongly that rapid and expeditious operation to close the rupture is the main goal of surgery.
This case implies that delayed rupture of the left ventricular psotinfarction aneurysm is always a threat even in apparently favorable presentation of left ventricular aneurysms. The rupture can occur not only during the first weeks of acute myocardial infarction but also after months, in patients suffering from myocardial infarction with true LV aneurysms. Therefore, awareness of this lethal complication and careful follow-up of such patients are important for the early diagnosis and successful surgical repair.
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References
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- Becker R.C., Gore J.M., Lambrew C., et al. A composite view of cardiac rupture in the United States National Registry of Myocardial Infarction. J Am Coll Cardiol 1996;27:1321-1326.[Abstract]
- Prêtre R., Benedikt P., Turina M.I. Experience with postinfarction left ventricular free wall rupture. Ann Thorac Surg 2000;69:1342-1345.[Abstract/Free Full Text]
- Dor V., Di Donato M., Sabatier M., Montiglio F., Civaia F., RESTORE Group. Left ventricular reconstruction by endoventricular circular patch plasty repair: a 17-year experience. Semin Thorac Cardiovasc Surg 2001;13(4):435-447.[Medline]
- Sakai K., Hosoda S., Shimamoto K. Late rupture of left ventricular true aneurysm after acute myocardial infarction. Clin Cardiol 1993;16(7):573-575.[Medline]
- Batts K.P., Ackermann D.M., Edwards W.D. Post-infarction rupture of the left ventricular free wall: clinicopathologic correlates in 100 consecutive autopsy cases. Human Pathol 1990;21:530.[Medline]
- Raudkivi P.J., Smyllie J., Conway N., Ross J.K. Rupture of a calcified true left ventricular aneurysm: echocardiographic diagnosis and successful repair. Eur J Cardiothorac Surg 1989;3:81-84.[Abstract]
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Abstract
Introduction
