Ann Thorac Surg 2005;80:1106-1108
© 2005 The Society of Thoracic Surgeons
Case report
Spontaneous Rupture of Left Ventricular True Aneurysm
Hung-Hsing Chao, MD,
Ming-Jen Lu, MD
*
,
Chi-Ren Hung, MD
Division of Cardiovascular Surgery, Department of Surgery, Shin Kong Wu Ho-Su Memorial Hospital, Taipei, Taiwan
Accepted for publication February 17, 2004.
* Address reprint requests to Dr Lu, Division of Cardiovascular Surgery, Department of Surgery, Shin Kong Wu Ho-Su Memorial Hospital, No. 95, Wen-Chang Rd, Shi-Lin District 111, Taipei, Taiwan; (Email: m000726{at}ms.skh.org.tw).
 |
Abstract
|
|---|
The rupture of left ventricular true aneurysm is a rare event. We report the case of a 52-year-old man who presented to the emergency department with cardiac tamponade that was due to a ruptured left ventricular true aneurysm. An emergency operation was successfully performed to address this rare event.
|
Introduction
|
|---|
The rupture of the left ventricle leading to cardiac tamponade is the cause of death in 5% to 10% of all cases of fatal acute myocardial infarction [1]. Free wall rupture is most likely to occur following an acute myocardial infarction. Pseudoaneurysm rupture, however, is less likely to occur. On the other hand, the late rupture of a true aneurysm of the left ventricle is extremely uncommon [2], because the fibrous scar comprising the wall of a true aneurysm is usually quite strong and is able to withstand the pressure generated by the remaining left ventricle [1]. We present the account of a successful surgical procedure performed on a patient presenting with the spontaneous rupture of a left ventricular true aneurysm.
A 52-year-old man with a medical history of hypertension was brought to the emergency department. He had not been receiving regular medical treatment. He was experiencing a sudden onset of severe chest pains radiating out to his back, accompanied by nausea, syncope, and cold sweating. His blood pressure was 88/50 mm Hg, his heart rate was 126 beats per minute, and his respiratory rate was 32 per minute. He appeared to be conscious but drowsy. He exhibited a distended neck vein, sinus tachycardia with no murmur, and a moist rales breathing sound over a bilateral lung base. Laboratory data, which included cardiac enzymes, were within the normal range. An electrocardiogram showed left ventricular hypertrophy and ST elevation at leads II, III, and aVF. Radiographic findings showed a widening mediasternum and cardiomegaly. An emergency computed tomographic scan revealed no specific findings other than a massive amount of pericardial effusion.
We were going to perform an emergency cardiac catheterization, but the patient’s condition was rapidly deteriorating. Immediately upon receiving the completed consent form from a family member, the patient was sent to the operating room. The operation found a bloody effusion (500 mL) over the pericardium cavity, an earlier inferior wall infarction with a large aneurysm with no pericardial adhesion, and a small leakage hole over the center of the aneurysm blocked by a blood clot (Fig 1). The aneurysm measured 5.8 cm in diameter, was composed of dense scar tissue ranging in thickness from 2 mm to 5 mm, and included a wide opening into the left ventricular chamber that involved at least 30% of the left ventricle (Fig 2). Under gross inspection, the coronary artery showed arteriosclerosis of the left anterior descending artery and the right coronary artery. Additionally, the left circumflex artery was small in size.
View larger version (160K):
[in this window]
[in a new window]
|
Fig 1. View of the inferior aspect of the heart showing the aneurysm (big arrow) and rupture site (small arrow).
|
|
A left ventricular aneurysmectomy with an endoventricular patch plasty was performed. A concomitant coronary artery bypass graft was also performed with a saphenous vein graft from the ascending aorta to the left anterior descending artery. The histologic finding of the resected aneurysm was fibrous tissue with hemorrhaging and a focal necrosis. This specimen did not display elements of myocardium because of the limited scope of the sample.
The patient had an uneventful recovery. A coronary angiographic evaluation of his coronary artery a week after the operation showed severe stenosis at the proximal part of the left anterior descending artery, that the saphenous vein graft bypassed to the left anterior descending artery was patent, that the left circumflex artery was patent but small in size, and a severe stenosis at the proximal part of the right coronary artery. Although his right coronary artery was severely stenotic, the patient complained of no discomfort and no further interventions were performed at that time. His ejection fraction was 35% when measured by echocardiography 2 weeks after the operation, and 57% at 6 months.
|
Comment
|
|---|
The term ventricular aneurysm applies to a circumscribed, thin-walled, noncontractile out pouching of the ventricle. Most develop in the setting of arteriosclerotic occlusive coronary artery disease following a transmural myocardial infarction [3]. Pathologically, ventricular aneurysms have been characterized as true and pseudoaneurysms [4, 5]. A true aneurysm is a gradual bulge of the wall that includes most of the fibrous tissue with additional elements of myocardium in the peripheral, with a wide diameter opening into the left ventricular chamber. A pseudoaneurysm is a rupture of the ventricular wall but with containment of the resulting hematoma or adhesive with pericardium. The hematoma becomes organized into a fibrous tissue that contains no elements of myocardium and often appears as a narrow-necked saccular dilation of the ventricle. The present case corresponds with this definition of a true aneurysm; however, the histologic finding did not display elements of myocardium because the limited excision of the specimen did not include peripheral tissue of the aneurysm.
An important difference, however, exists with regard to the potential for rupture of a true aneurysm compared with a pseudoaneurysm. In the early stages of the development of a true aneurysm, about 2 to 3 weeks after the onset of the underlying myocardial infarction, a rupture through the center of the aneurysm may occur. With the onset of the fibrous stage of a true aneurysm, the occurrence of a rupture becomes very unlikely. This situation stands in marked contrast to a pseudoaneurysm, which may rupture not only during the early stages of its development but also during the established fibrous stage [4].
Few cases of the rupture of a left ventricular true aneurysm have been reported [6, 7]. Since, in most cases, the rupture of an aneurysm leads rapidly to cardiac tamponade and death, most diagnoses of this event have been made during autopsy. In the present patient, a relatively large left ventricular true aneurysm had resulted from an apparently silent myocardial infarction. The patient was brought to the emergency department with cardiac tamponade that was due to a left ventricular true aneurysm rupture. Fortunately for the patient, the amount of leakage was tolerable and the hole happened to be blocked by a blood clot. That bought him the time he needed to get to the hospital where, notwithstanding the seriousness of his condition, a successful emergency operation was performed. Although the histologic findings were inconclusive, this rare event was confirmed through gross inspection.
|
References
|
|---|
- Rosenthal JE, Daroca PJ, Cohen LS. Rupture of chronic left ventricular aneurysm after acute coronary thrombosis Amer J Cardiol 1972;30:547-549.[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]
- Friedman BM, Dunn MI. Postinfarction ventricular aneurysms Clin Cardiol 1995;18:505-511.[Medline]
- Vlodaver Z, Coe JI, Edwards JE. True and false left ventricular aneurysmsPropensity for the latter to rupture. Circulation 1975;51(3):567-572.[Abstract/Free Full Text]
- Buehler DL, Stinson EB, Oyer PE, Shumway NE. Surgical treatment of aneurysms of the inferior left ventricular wall J Thorac Cardiovasc Surg 1979;78(1):74-78.[Abstract]
- Raudkivi PJ, Smyllie J, Conway N, Ross JK. Rupture of a calcified true left ventricular aneurysmechocardiographic diagnosis and successful repair. Eur J Cardiothorac Surg 1989;3(1):81-84.[Abstract]
- Matsumoto M, Konishi Y, Nishizawa J, Yuasa S, Kotoura H. Successful surgical treatment of a ruptured true postinfarction left ventricular aneurysm–a case report Jpn Circ J 1993;57(12):1183-1186.[Medline]
Top
Abstract
Introduction
