Ann Thorac Surg 2010;89:642. doi:10.1016/j.athoracsur.2009.04.119
© 2010 The Society of Thoracic Surgeons
Images in Cardiothoracic Surgery
Necessitating, Recurrent Pseudoaneurysm of the Left Ventricle
Rammohan Marla, MD,
Alfred C. Nicolosi, MD*
Division of Cardiothoracic Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin
* Address correspondence to Dr Nicolosi, Division of Cardiothoracic Surgery, Medical College of Wisconsin, Froedtert Hospital, East Clinics, 9200 W. Wisconsin Ave, Milwaukee, WI 53226 (Email: nicolosi{at}mcw.edu).
A 73-year-old woman suffered a myocardial infarction from acute occlusion of the left anterior descending coronary artery. Several days later the left ventricular apex ruptured, which required emergency surgical closure. Six weeks later, a pseudoaneurysm of the left ventricular apex developed, which was repaired by suturing a large, glutaraldehyde-fixed, bovine pericardial patch to the epicardium around the apex of the heart. Nine months later, she presented with subacute, left-sided chest pain, with a pulsating bulge between her ribs, and she was referred to our institution. Echocardiogram demonstrated a large pseudoaneurysm arising from the left ventricular apex (Fig 1;
asterisk). Cardiac gated magnetic resonance imaging showed a 9 x 8 cm, multi-septated pseudoaneurysm arising from the left ventricular apex, protruding through the left chest wall between the ribs (Fig 2). She underwent reoperation, where the pericardial patch used for the prior repair was found detached from the heart (Fig 3A). The pseudoaneurysm tissue was resected, leaving a rim of scar around the defect in the true left ventricular apex. The defect was closed with a small bovine pericardial patch (Fig 3B) and the rim of scar tissue was closed over the patch. The patient made an uneventful recovery.
Left ventricular pseudoaneurysms are rare but can arise after myocardial infarction, trauma, or cardiac surgery. Prompt surgical treatment of a pseudoaneurysm is generally necessary to prevent fatal rupture. This report demonstrates important points regarding diagnosis and surgical treatment. Cardiac gated magnetic resonance imaging is an excellent imaging modality, as it provides complete anatomical information. Secure closure, using the scar directly around the defect to anchor suture for a patch is important to prevent recurrence.
