Ann Thorac Surg 2004;78:1823-1825
© 2004 The Society of Thoracic Surgeons
Case report
Giant Left Ventricular Pseudoaneurysm After Mitral Valve Replacement and Myocardial Infarction
Yujiro Hirasawa, MD*,a,
Tadamasa Miyauchi, MDa,
Toshihiko Sawamura, MDa,
Hiroshi Takiya, MDa
a Division of Cardiovascular Surgery, Gifu Prefectural Gifu Hospital, Gifu, Japan
Accepted for publication July 17, 2003.
* Address reprint requests to Dr Hirasawa, Gifu Prefectural Gifu Hospital, 4-6-1 Noisshiki Gifu City, Gifu 500-8226, Japan
hirayuji{at}fancy.ocn.ne.jp
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Abstract
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Left ventricular pseudoaneurysm is a rare but serious complication of mitral valve replacement or myocardial infarction. Prompt surgical correction is mandatory in cases of a large left ventricular pseudoaneurysm. A 70-year-old man had a giant left ventricular pseudoaneurysm after myocardial infarction and mitral valve replacement. The orifice of the pseudoaneurysm was closed with an e-polytetrafluoroethylene patch and the pseudoaneurysmal wall was almost resected.
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Introduction
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Left ventricular pseudoaneurysm develops after rupture of the ventricular wall in an area of pericardial adhesion; this has been recognized historically as a possible sequela of mitral valve replacement and myocardial infarction. Left ventricular pseudoaneurysm is a rare but serious complication. Although there may be a role for nonoperative treatment in cases of small pseudoaneurysms, the presence of large pseudoaneurysms usually mandates surgical intervention. We describe a patient with a giant left ventricular pseudoaneurysm caused by mitral valve replacement and myocardial infarction.
A 70-year-old man was admitted to our hospital with no symptoms. He had a past history of acute myocardial infarction 2 years previously with the culprit lesion in the left circumflex coronary artery. He had also undergone percutaneous transluminal coronary angioplasty at another hospital, but it was unsuccessful. After a few weeks he had dyspnea on effort develop and he was diagnosed with a New York Heart Association function class II. Echocardiography revealed mitral regurgitation (Sellers' classification, class IV) that was due to destruction of the posterior papillary muscle. He underwent mitral valve replacement with a 27 St. Jude mechanical prosthesis. His recovery was uneventful and he was discharged home on postoperative day 20. Echocardiography was regularly performed at the outpatient clinic and revealed a gradually enlarging left ventricular pseudoaneurysm (Fig 1). No thrombotic material was detected within the pseudoaneurysm. The prosthetic mitral valve was functioning normally without paravalvular leak on echocardiography. Computed tomographic studies also demonstrated the lesion that had originated from the left ventricular posterolateral wall and measured 7 cm in diameter, and at this stage he was referred to our hospital. We thought this case was an indication for left ventricular aneurysmectomy, and preoperative cardiac catheterization was performed. The left circumflex coronary artery was occluded at number 11 and the distal portion was not visualized. Left ventriculography revealed a giant left ventricular pseudoaneurysm (Fig 2). Results of pressure study with a Swan-Ganz catheter were in the normal range. Myocardial perfusion imaging revealed no viability of the left ventricular posterolateral wall, so additional coronary artery bypass grafting was not planned.
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Fig 1. Preoperative echocardiogram (parasternal short-axis view) showing a large left ventricular pseudoaneurysm originated from the posterolateral left ventricular wall. Dotted line = the diameter of the orifice (5.42 cm measured by echocardiogram). (LV = left ventricle; O = orifice of pseudoaneurysm; P = pseudoaneurysm.)
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Fig 2. Preoperative left ventriculography in the left anterior oblique projection showing a large left ventricular pseudoaneurysm. (LV = left ventricle; O = orifice of pseudoaneurysm; P = pseudoaneurysm.)
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After the patient was positioned, the right femoral artery and vein were exposed and the left lateral thoracotomy was performed in the fifth intercostal space. We selected this approach because median sternotomy had been performed at the previous operation and exposure of the lesion by retracting the heart could thus be avoided. With selective ventilation, the left lung was collapsed, and the left ventricular pseudoaneurysm was found (Fig 3); it was almost free of adhesions and originated from the left ventricular posterolateral wall. First we tried to establish cardiopulmonary bypass through cannulation of the right femoral artery and right femoral vein; however it was unsuccessful because of insufficient venous drainage. We were able to establish cardiopulmonary bypass by additional cannulation of the pulmonary trunk. After ventricular fibrillation was induced electrically, the pseudoaneurysm was incised longitudinally. The orifice of the pseudoaneurysm was large and measured 6 cm in diameter. The edge of the orifice was densely fibrotic, and the posterior papillary muscle was in the proximity of the edge. The posterior leaflet of the mitral valve and chordae showed no remarkable abnormality. The mechanical prosthesis and its surroundings were normal. The orifice of the pseudoaneurysm was closed with an e- polytetrafluoroethylene patch. The pseudoaneurysmal wall was almost completely resected, and it was closed by means of direct suture. Pathologic examination of the pseudoaneurysmal wall revealed no myocardial tissue. The patient's recovery was uneventful, and he was discharged home on postoperative day 14. The patient was well and symptom free 7 months postoperatively.
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Fig 3. An intraoperative view of a giant left ventricular pseudoaneurysm was recognized (in the lower middle). (P = pseudoaneurysm.)
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Comment
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Acquired left ventricular pseudoaneurysms develop after myocardial infarction, surgery, trauma, or infection [1]. Postsurgical pseudoaneurysms occur after replacement of the mitral valve or arise at a previous ventriculotomy site [2]. This complication occurs in 0.02% to 2.0% of mitral valve replacements [2, 3]. Predisposing factors include resection of the posterior leaflet, overzealous decalcification of the annulus, insertion of an oversized prosthesis, and redo mitral valve replacement. The main cause of pseudoaneurysm in our case was mitral valve replacement, because the enlarging pseudoaneurysm was found after mitral valve replacement, but the combination of myocardial infarction facilitated the formation of a giant pseudoaneurysm. Although the presence of a narrow neck is strongly suggestive of a pseudoaneurysm [4], the orifice of the pseudoaneurysm in our case was very large and was impossible to repair by direct closure. A pseudoaneurysm more than 3 cm in diameter is an operative indication in chronic and asymptomatic pseudoaneurysms [4], and this indication applied in our case.
The left thoracotomy approach was a better option because ablation of extensive adhesions is usually required at reoperation when approached by a repeated median sternotomy, as in our case. Furthermore, exposure of the lesion by retracting the heart is avoided by the left thoracotomy approach [5]. Pseudoaneurysms are repaired from outside or inside of the heart. The advantages of internal repair are: less than 1 more than better exposure of the subannular apparatus is obtained, making repair straightforward; less than 2 more than additional cardiac abnormalities can be repaired simultaneously; and less than 3 more than the left circumflex coronary artery is better protected than with external repair [5]. The advantages of external repair are: less than 1 more than access to the pseudoaneurysm is not restricted by a small mitral annulus; less than 2 more than the prosthetic mitral valve does not need to be explanted for exposure and repair of the rupture site; and less than 3 more than the pseudoaneurysm can be resected [4, 5]. We repaired the pseudoaneurysm from an external approach because no other intracardiac disease or prosthetic mitral valve dysfunction was recognized. It is conceivable that the left thoracotomy approach and the external approach are more appropriate in cases of pseudoaneurysm after mitral valve replacement (in which a median sternotomy has been performed) with normal function of the prosthetic mitral valve.
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References
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- Fraces C, Romero A, Grady D. Left ventricular pseudoaneurysm. J Am Coll Cardiol. 1998;32:557–561[Abstract/Free Full Text]
- Sakai K, Nakamura K, Ishizuka N, Nakagawa M, Hosoda S. Echocardiographic findings and clinical features of left ventricular pseudoaneurysm after mitral valve replacement. Am Heart J. 1992;124:975–982[Medline]
- Becker RC, Gore JM, 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]
- Rene P, Andre L, Rolf J, Turina MI. Surgical treatment of acquired left ventricular pseudoaneurysm. Ann Thorac Surg. 2000;70:553–557[Abstract/Free Full Text]
- Ono M, Randall KW. Left ventricular pseudoaneurysm late after mitral valve replacement. Ann Thorac Surg. 2002;73:1303–1305[Abstract/Free Full Text]
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Abstract
Introduction
