Ann Thorac Surg 2007;84:657-659
© 2007 The Society of Thoracic Surgeons
Case Reports
Protruding Left Intercostal Mass After Left Ventricular Aneurysmectomy
Giuseppe D’Ancona, MDa,*,
Giuseppe Mamone, MDb,
Gianluca Marrone, MDb,
Francesco Pirone, MDa,
Gianluca Santise, MDa,
Sergio Sciacca, MDa,
Michele Pilato, MDa
a Department of Cardiothoracic Surgery, Mediterranean Institute for Transplantation and Advanced Specialized Therapies, University of Pittsburgh Medical Center, Palermo, Italy
b Department of Radiology, Mediterranean Institute for Transplantation and Advanced Specialized Therapies, University of Pittsburgh Medical Center, Palermo, Italy
Accepted for publication March 23, 2007.
* Address correspondence to Dr D’Ancona, Department of Cardiothoracic Surgery, Mediterranean Institute for Transplantation and Advanced Specialized Therapies, University of Pittsburgh Medical Center, Via Tricomi 1, Palermo, 90127, Italy (Email: gdancona{at}ismett.edu).
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Abstract
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In this report we summarize a case of myocardial infarction that developed an apical ventricular aneurysm, which was surgically removed to re-expand and reappear as a pulsating chest wall mass 16 years later.
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Introduction
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Cardiocutaneous fistula is a treacherous complication that may occur after a left ventricular aneurysmectomy. Although the condition has a rare presentation, this possible diagnosis should be considered before performing any invasive diagnostic or interventional procedure. Surgical correction of ventricular cutaneous fistula should be adequately planned using modern diagnostic tools and avoiding unnecessary tests that could potentially destabilize these already compromised patients.
A 71-year-old man was referred to our hospital for onset of left chest discomfort. He had undergone a surgical intervention 16 years prior for myocardial revascularization and left ventricular aneurysmectomy. The patient reported the recurrence of left chest pain in the last 4 months, associated with a protruding 3 x 4 cm mass in the left fifth intercostal space. After admission to a thoracic unit where a biopsy of the mass was attempted and abandoned, he underwent a left ventriculography that confirmed the presence of a left ventricular aneurysm and the suspected fistula between the left ventricle and the chest wall (Fig 1). The patient was admitted into our cardiac surgery unit where a chest angiographic computed tomographic scan with three-dimensional reconstruction was performed to understand the exact topography and extension of the left ventricular aneurysm and to evaluate the patency of the three aortocoronary grafts in vision of redo surgery (Figs 2A,
3).
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Fig 2. (Left) Computed tomographic image reconstruction of left ventricular aneurysm: notice extension into subcutaneous layers. (Right) Intraoperative findings of a large pseudoaneurysm delimited by a large organized clot, shaped as a left ventricular cast.
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Fig 3. Computed tomographic three-dimensional imaged reconstruction of left ventricular pseudoaneurysm.
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In light of the patient’s critical conditions, we opted for surgical resection of the ventricular aneurysm. After cannulation of the femoral vessels and initiation of cardiopulmonary bypass, the sternum was re-entered trough a midline incision. Cardiac arrest was achieved with antegrade cold cardioplegia and the left ventricle was approached after lysis of dense adhesions. A large pseudoaneurysm pouch was noticed, originating from the left ventricular anterolateral wall (where the previous aneurysmectomy had been performed) and extending into the subcutaneous layers through the intercostal muscular wall. The pseudoaneurysm was delimited by a large organized clot, shaped as a left ventricular cast (Fig 2B). After dissecting the dense adhesions, it appeared that the suture of the previous linear aneurysmectomy had dehisced and the left ventricular cavity was wide open, with the margins of the ventricular resection standing apart (Fig 4).
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Fig 4. (Left) See the dehisced left ventricular aneurysmectomy after removal of pseudoaneurysm clot. (Right) Final repair of left ventricle with Dacron patch (Boston Scientific, Wayne, NJ).
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After a reductive posterior annuloplasty of the mitral valve through the left ventricle, a redo ventriculoplasty was performed with a Dacron patch (Boston Scientific, Wayne, NJ) (Fig 4). The margins of the previous ventriculectomy were also approximated over the patch.
At the end of the procedure, the patient was transferred to the intensive care unit in marginal hemodynamic condition with maximal inotropic support and an intraaortic balloon pump. His ventricular function improved in the following days, and he was eventually weaned off all cardiac support. The postoperative period was complicated by respiratory failure requiring prolonged intubation and tracheostomy. After 25 days of hospitalization, he was eventually discharged in stable hemodynamic and respiratory condition.
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Comment
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Cardiac cutaneous fistula is a described complication occurring after left ventricular aneurysmectomy [1–4]. Although this condition has a rare presentation, its possible diagnosis should be considered before performing any invasive diagnostic or interventional procedure. Adequate cardiac diagnostic imaging should be routinely performed to safely approach this condition by selecting the most appropriate surgical strategy. In our experience, three-dimensional reconstruction of cardiac computed tomography and computed tomographic angiography can guarantee a safer and case-tailored approach to ventricular cutaneous fistula, reproducing its topography and extension. At the same time, modern computed tomographic technology can give accurate information concerning the patency and spatial location of previously constructed coronary grafts.
In this context, additional invasive investigation (such as standard ventriculography and coronary angiography) could be superfluous and almost contraindicated in these already compromised patients.
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References
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- Danias PG, Lehman T, Kartis T, Missri JC. Cardiocutaneous fistula Heart 1999;81:325-326.[Abstract/Free Full Text]
- Wellens F, Vanermen H. Treatment of the infected cardiac suture line J Card Surg 1988;3:109-118.[Medline]
- Deuvaert FE, Wellens F, De Paepe J, Primo G. Cardiocutaneous fistula after left ventricular aneurysm repairCase report and review of the literature. J Cardiovasc Surg (Torino) 1984;25:560-562.[Medline]
- Kaul S, Josephson MA, Tei C, et al. Atypical echocardiographic and angiographic presentation of a postoperative pseudoaneurysm of the left ventricle after repair of a true aneurysm J Am Coll Cardiol 1983;2:780-784.[Abstract]
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Abstract
Introduction
