Ann Thorac Surg 2007;84:266-269
© 2007 The Society of Thoracic Surgeons
Case Reports
Delayed Left Ventricular Pseudoaneurysms After Left Ventricular Aneurysm Repairs With the CorRestore Patch
Tomer Z. Karas, MD,
Igor D. Gregoric, MD,
O.H. Frazier, MD,
Ross M. Reul, MD*
Department of Cardiovascular Surgery, The Texas Heart Institute at St. Luke’s Episcopal Hospital, Houston, Texas
Accepted for publication February 5, 2007.
* Address correspondence to Dr Reul, The Texas Heart Institute at St. Luke’s Episcopal Hospital, P.O. Box 20345, MC 3-258, Houston, TX 77225-0345 (Email: rreul{at}heart.thi.tmc.edu).
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Abstract
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We present two cases of left ventricular pseudoaneurysm that developed after left ventricular aneurysm repair with the CorRestore patch (Somanetics Corp, Troy, MI). Both patients underwent subsequent pseudoaneurysm repair with Dacron patches (Boston Scientific Corp, Natick, MA). We discuss the physiologic limitations of the CorRestore patch and the causes of pseudoaneurysms that arise after left ventricular aneurysm repair.
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Introduction
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The first successful repair of a left ventricular aneurysm was described in 1958 by Cooley and colleagues [1], who also reported the first such repair with a Dacron patch (Boston Scientific Corp, Natick, MA) in 1989 [2]. Soon thereafter, woven Dacron became the material of choice for these patch repairs because of its durability, flexibility, and availability. Nonetheless, in recent years, other materials have become available that are potentially even better suited for aneurysm patching. Recently we have had experience using a relatively new bovine pericardial system—the CorRestore patch (Somanetics Corp, Troy, MI)—in place of the Dacron patch (Boston Scientific Corp). We report two cases of pseudoaneurysm related to the use of the CorRestore patch (Somanetics Corp) and consider their possible causes.
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Case Reports
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Patient 1
A 60-year-old man who reported 36 hours of retrosternal chest pain was diagnosed with acute myocardial infarction in an anterolateral distribution. Cardiac catheterization showed occluded left anterior descending and right coronary arteries and 50% stenosis of the circumflex coronary artery. A left ventriculogram revealed a large anteroapical aneurysm and an ejection fraction of approximately 25%. After 1 month of convalescence without further incident, the patient underwent three-vessel coronary artery bypass grafting and left ventricular aneurysm repair with a CorRestore patch. Thrombus was carefully evacuated from within the aneurysm. A Fontan stitch of 2-0 Prolene (Ethicon, Somerville, NJ) was placed around the contracting, viable margin of the aneurysm. A medium CorRestore patch was selected for the repair. Pledgeted 0 Ethibond horizontal mattress sutures (Ethicon) were placed circumferentially with the pledgets below the Fontan suture. On the septal side, the sutures were brought out above the Fontan stitch. On the free wall of the left ventricle, the sutures were brought through the ventricle and through a strip of pericardium. The sutures were then passed through the sewing ring of thickened pericardium on the CorRestore patch. The margin of the patch was reinforced circumferentially with a continuous 2-0 Prolene suture. The aneurysm was closed over the patch in a pants-over-vest technique using 0 Ethibond horizontal mattress sutures through pericardial strips reinforced with continuous 2-0 Prolene sutures. The repair was hemostatic, and after appropriate removal of air, the patient was weaned from cardiopulmonary bypass with inotropic support.
The patient’s hospital course was uneventful. He was extubated on the day of surgery and transferred from the intensive care unit the next day. He was discharged from the hospital on postoperative day 10.
Two years later, the patient presented to another hospital with features of acute embolism to the left leg. He was given thrombolytic therapy and systemic heparin. Within several hours of anticoagulation, a mass developed on the left anterior chest wall, increased in size, and became pulsatile. An echocardiogram showed this mass to be a left ventricular pseudoaneurysm with mural thrombus. The patient was transferred to our institution, where cardiac magnetic resonance imaging confirmed the diagnosis of a 10-cm pseudoaneurysm involving the left ventricle (Fig 1).
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Fig 1. Patient 1: Transverse (left) and sagittal (right) magnetic resonance images of the left ventricular pseudoaneurysm extending into the chest wall.
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The patient was brought to the operating room to address the left ventricular pseudoaneurysm. The left ventricle was found to be densely adherent to the chest wall and was dissected free after cardiopulmonary bypass and diastolic cardioplegic arrest were established. The oversewn aneurysmal wall had opened, and the pericardial patch portion of the CorRestore system had separated from the sewing ring, which was still attached within the ventricle. The patch was not identified and was presumed to have been incorporated into the scar tissue along the chest wall.
The CorRestore sewing ring was excised. A new Fontan stitch was placed, and the defect was repaired as before, this time with a Dacron patch. The patient tolerated the procedure well. He was discharged without incident on postoperative day 9. At follow-up 6 months later, the patient was doing well, with no evidence of recurrence of pseudoaneurysm.
Patient 2
A 67-year-old man was admitted with a dilated cardiomyopathy and an ejection fraction of 30%. Risk factors included diabetes mellitus, hyperlipidemia, and heavy tobacco use. A small left ventricular aneurysm was identified. Cardiac catheterization revealed severe three-vessel coronary artery disease. The patient underwent four-vessel coronary artery bypass grafting followed by repair of his left ventricular aneurysm with a CorRestore patch, by using a technique similar to that used in patient 1. The patient had a protracted hospital course, during which respiratory insufficiency, sternal dehiscence requiring debridement, and ultimately pectoralis major and rectus abdominus flap coverage developed. He required extensive rehabilitation.
Three months after his initial operation, the patient was readmitted with acute decompensation from congestive heart failure and sepsis. After the patient was stabilized, magnetic resonance imaging found a pseudoaneurysm adjacent to the site of the previous left ventricular aneurysm repair (Fig 2). There was evidence of slow bleeding into the pericardium, with blood tracking retrosternally and around the apices of the left and right ventricles.
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Fig 2. Patient 2: Coronal (left) and sagittal (right) magnetic resonance images of the perforated left ventricular pseudoaneurysm with free-flowing blood in the pericardium. The arrow indicates a jet—a sign of blood flow—between the ventricle and the aneurysm.
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The patient returned to the operating room for repair of the pseudoaneurysm. Because of the previous sternal dehiscence and flap coverage, the heart was approached through a left thoracotomy. Cardiopulmonary bypass was established through the left common femoral artery and vein. The CorRestore patch was removed, which exhibited evidence of dehiscence of the sewing ring from the patch. The defect was repaired with Dacron and aneurysmorrhaphy, as in the previous patient.
The patient’s initial postoperative course was remarkable for dramatic improvement in left ventricular function. Unfortunately, deconditioning from the patient’s recent hospitalization and persistent respiratory insufficiency degenerated to multiorgan failure. Support was withdrawn after discussions with his family, and he died 6 weeks after his second operation.
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Comment
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Ventricular pseudoaneurysm is a rare complication of aneurysm repair. Various surgical treatments for these pseudoaneurysms have been described [3–6], including primary repair, patch repair with biologic or synthetic materials, and the use of pedicled flaps made from a variety of tissues, including omentum, pericardium, and even the pectoralis major [5]. Several potential causes of ventricular pseudoaneurysm have been identified, including acute myocardial infarction, trauma, and bacterial infection [4].
Clearly, the principles of repair must be tailored to the cause of the pseudoaneurysm. Traumatic pseudoaneurysms are usually amenable to primary repair. In contrast, there is little reported experience in repairing pseudoaneurysms that form after ventricular aneurysm repair, which may result from infections related to the Teflon strips (Bard Peripheral Vascular Inc, Tempe, AZ) placed on the surface of the repaired area [7]. However, in the present cases, pseudoaneurysm resulted from mechanical failure of the prosthesis, which simply required replacement with a more reliable patch.
The CorRestore patch consists of an oval piece of glutaraldehyde-fixed bovine pericardium surrounded by an integrated glutaraldehyde-fixed pericardial suture bolster. The patch is designed for ventricular restoration procedures. Its proposed advantage over other patches relates to the increased thickness of the sewing ring, which was "engineered to fill the irregular contours of the akinetic trabeculated endocardium typically seen in thick-walled, infarcted segments..." [8].
We believe that these are the first reported cases of this complication associated with the use of the CorRestore patch. It appears that the patch portion had separated from the sewing ring. In both cases, this dehiscence allowed formation of pseudoaneurysms. The oversewn aneurysmal tissue used to reinforce each patch repair was insufficient to prevent pseudoaneurysm formation once the patch had failed.
The suture bolster of the CorRestore system is fixed to viable ventricular tissue during aneurysm repair. With each contraction of the involved ventricle, the attachment between the bolster and the patch portion of the CorRestore system must endure both rotational and transverse forces. We believe that in time this attachment can be disrupted by these repetitive stresses, resulting in pseudoaneurysm formation. We have not seen this complication in patients who have undergone aneurysm repair with the endoaneurysmorrhaphy technique that we typically use [9].
We postulate that in the first case, the pseudoaneurysm developed before the patient presented with limb ischemia. The embolus that produced the ischemia probably originated from thrombus within the pseudoaneurysm. The combination of clopidogrel, thrombolytic therapy, and systemic anticoagulation caused acute expansion of the pseudoaneurysm. Fortunately, the expansion occurred in a setting in which the precarious situation was recognized rapidly, and surgical intervention could be performed in a timely fashion to avoid catastrophic rupture.
In the second case, the dehiscence may have been associated with ongoing low-grade mediastinitis. The bleeding that ensued necessitated emergent reoperation on a de-conditioned patient with a predictably morbid result. We believe that these two cases are the only instances of failure after use of the CorRestore patch in our institution.
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Acknowledgments
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Stephen N. Palmer, PhD, ELS, provided editorial support.
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References
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- Cooley DA, Collins HA, Morris Jr GC, Chapman DW. Ventricular aneurysm after myocardial infarction: surgical excision with use of temporary cardiopulmonary bypass JAMA 1958;167:557-560.[Abstract/Free Full Text]
- Cooley DA. Ventricular endoaneurysmorrhaphy: a simplified repair for extensive postinfarction aneurysm J Card Surg 1989;4:200-205.[Medline]
- Mackenzie JW, Lemole GM. Pseudoaneurysm of the left ventricle Tex Heart Inst J 1994;21:296-301.[Medline]
- Bluett M, Bolling SF, Kirsh MM. Management of recurrent ventricular pseudoaneurysm Tex Heart Inst J 1991;18:69-71.[Medline]
- Akinci E, Isik O, Tekumit H, et al. Three ventriculoplasty techniques applied to three left-ventricular pseudoaneurysms in the same patient Tex Heart Inst J 1999;26:87-89.[Medline]
- Adkins MS, Laub GW, Pollock SB, Fernandez J, McGrath LB. Left ventricular pseudoaneurysm with hemoptysis Ann Thorac Surg 1991;51:476-478.[Abstract]
- Cooley DA, Frazier OH, Duncan JM, Reul GJ, Krajcer Z. Intracavitary repair of ventricular aneurysm and regional dyskinesia Ann Surg 1992;215:417-423.[Medline]
- Somanetics Corporation. Surgical ventricular restoration (SVR) with the CorRestore system. Available at: http://www.somanetics.com/pdf/CR%20SMS297QA.pdf. Accessed July 17, 2006.
- Gregoric ID, Cooley DA. Ventricular aneurysmsIn: Yang SC, Cameron DE, editors. Current therapy in thoracic and cardiovascular surgery. Philadelphia, PA: Mosby; 2004. pp. 675-677.
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Abstract
Introduction
