Ann Thorac Surg 2005;79:1031-1032
© 2005 The Society of Thoracic Surgeons
Case report
Submitral Left Ventricular Pseudoaneurysm
Marjan Jahangiri, FRCSa,*,
David Sarkar, MRCPa,
Paul Quinton, FRCAa,
David E. Ward, FRCPa
a Department of Cardiac Surgery, Cardiology and Cardiac Anesthesia, St. George's Hospital and Medical School, London, United Kingdom
Accepted for publication September 10, 2003.
* Address reprint requests to Dr Jahangiri, Department of Cardiac Surgery, St. George's Hospital and Medical School, Blackshaw Rd, London SW17 OQT, UK
marjan.jahangiri{at}stgeorges.nhs.uk
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Abstract
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We describe a successful transatrial repair in a patient with left ventricular pseudoaneurysm in the submitral position after a myocardial infarct.
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Introduction
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Pathologically, true aneurysms of the ventricle are thought to arise from expansion and thinning in an area of transmural infarct, whereas false aneurysms result from containment of ventricular rupture by pericardial adhesions. However, this separation is often difficult. Submitral left ventricular (LV) aneurysm is a rare anomaly, mainly congenital, occurring in patients of African origin [1]. In the majority of patients, the aneurysm grows behind the left atrium, involving the posterior mitral valve apparatus and resulting in mitral regurgitation.
We describe a patient with an LV pseudoaneurysm in the submitral position after a myocardial infarct who underwent repair.
A 60-year-old woman was referred 5 months after a myocardial infarct with an LV pseudoaneurysm. She underwent coronary angiography, which showed a completely blocked circumflex vessel with normal left anterior descending and right coronary arteries. While an inpatient, she had a cerebrovascular accident that caused left-sided weakness. Transthoracic and transesophageal echocardiography showed a wide-necked aneurysm in free communication with the LV cavity, lying just underneath the posterior leaflet of the mitral valve, with mild mitral regurgitation (Fig 1). Magnetic resonance imaging measured the pseudoaneurysm at 10 x 5.7 x 8 cm (Fig 2).
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Fig 1. (A) Parasternal long-axis image demonstrating a large pseudoaneurysm communicating with the left ventricle (LV). (B) Doppler color flow mapping reveals flow into the aneurysm cavity (AC). (AML = anterior mitral leaflet; Ao = aorta; LA = left atrium.)
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Fig 2. Magnetic resonance image showing that in the territory of the circumflex artery, the left ventricle has ruptured, resulting in a large pseudoaneurysm with thrombosis in its apicolateral aspect (arrow).
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Before the surgical intervention, the patient was moderately short of breath, and her left-sided weakness had partially resolved. It was decided that the aneurysm was not suitable for excision because of its close proximity to the mitral valve apparatus. During the procedure, severe adhesions were present, and minimal dissection was performed. Cardiopulmonary bypass was established by cannulation of the ascending aorta and bicaval cannulation at 30°C. The myocardium was arrested with cold antegrade blood-based cardioplegic solution. The mitral valve was exposed through the left atrium. The opening to the pseudoaneurysm was just posterior and inferior to the posterior leaflet, measuring 5 cm. This was not suitable for direct closure, because it would have distorted the valve structure. The opening was closed using 2-0 Ethibond pledgeted sutures (Ethicon, Somerville, NJ) in an interrupted mattress fashion with a patch of Dacron (DuPont, Wilmington, DE). To obtain access to the opening, the posterior papillary muscle had to be divided and was subsequently repaired with a Gore-Tex suture (W. L. Gore and Associates, Flagstaff, AZ). The patient was weaned off bypass, on 5 µg · kg–1 · min of dopamine. Transesophageal echocardiography showed satisfactory repair with minimal mitral regurgitation. She remained stable and was extubated 12 hours postoperatively. Her left-sided weakness had worsened. She was discharged to her local hospital at 10 days for rehabilitation. At 3-month follow-up, her clinical status had improved considerably. Echocardiography showed satisfactory repair, with shrinkage of the aneurysm and no mitral regurgitation.
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Comment
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Posterior submitral LV aneurysm is a rare entity. The majority of cases are congenital and seen in patients of African origin presenting in their 20s or 30s. These aneurysms, which are often multiloculated, tend to grow into the pericardial space expanding behind the left atrium or the LV. The posterior mitral leaflet becomes incorporated in the roof of the aneurysm, causing regurgitation [1]. These aneurysms are different from those caused by ischemia. Characteristically, in the congenital variety, the aneurysms have large cavities separated from the left ventricle by a well-defined neck, situated posterior to the mitral valve annulus. Although the aneurysm in this case was due to ischemia, it resembled the congenital variety.
The first successful repair of an aneurysm of the base of the LV was reported in 1963, in which the neck of the aneurysm was exposed through its free wall and the defect was primarily closed [2]. In the congenital variety due to the variable direction of expansion of the aneurysm and the presence of pericardial adhesions, the conventional ventricular approach is difficult. In the patient described, because of the presence of severe adhesions and the very close proximity to the mitral valve, the ventricular approach and excision of the aneurysm were not feasible. Therefore, access to the neck was obtained through the mitral orifice. However, there are successful reports of repair using the LV approach and excision [3, 4]. Antunes [1] described a transatrial approach whereby a left atriotomy is made, and then an incision is made parallel to the posterior part of the annulus that exposes the aneurysmal cavity and neck. The neck of the aneurysm is then closed from inside the cavity without disrupting the valvar apparatus. Using this approach, access to the neck is unimpeded by the chordae, in contrast to that obtained through the valve. However, this approach is not always suitable for all subvalvar aneurysms because of the variability of the relationship of the aneurysm neck to the valve. Antunes [1] used direct closure successfully in 9 patients. We used patch repair to avoid distortion of the mitral valve. There are reports of primary closure causing mitral incompetence and necessitating mitral valve replacement in posterior subvalvar aneurysms [5] and causing both mitral and aortic insufficiency in anterior subvalvar aneurysms [6].
We have reported a patient with ischemic submitral pseudoaneurysm resembling the congenital variety. Because of the proximity of the mitral valve apparatus to the aneurysm, excision of the aneurysm was not feasible. The patient underwent patch closure of the neck of the aneurysm and made a satisfactory recovery.
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References
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- Antunes M. Submitral left ventricular aneurysms. J Thorac Cardiovasc Surg. 1987;94:24105
- Shrire V, Barnard CN. The surgical cure of a cardiac aneurysm of unknown cause. J Cardiovasc Surg. 1963;4:5–9[Medline]
- Sorensen MB, Moat NE, Mohiaddin RH. False left ventricular aneurysm documented by magnetic resonance imaging. Circulation. 2002;105:1734[Free Full Text]
- Konstantinov I, Mickleborough LL, Graba J, Merchant N. Intraventricular mitral annuloplasty technique for use with repair of posterior left ventricular aneurysm. J Thorac Cardiovasc Surg. 2001;122:1244–1247[Free Full Text]
- Wolpowitz A, Arman B, Barnard MS, Barnard CN. Annular subvalvular idiopathic left ventricular aneurysms in the black African. Ann Thorac Surg. 1979;27:350–355[Abstract]
- Kriuthoff WA, Akl BF, Blacky AR. Surgical repair of an anterior mitral subvalvular aneurysm. Ann Thorac Surg. 1995;59:1001–1003[Abstract/Free Full Text]
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T. Miura, K. Yamazaki, S. Kihara, S. Saito, M. Miyagishima, S. Aomi, and H. Kurosawa
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Ann. Thorac. Surg.,
February 1, 2008;
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643 - 645.
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