Ann Thorac Surg 2011;91:1596-1597. doi:10.1016/j.athoracsur.2010.10.024
© 2011 The Society of Thoracic Surgeons
Case Reports
Patch Repair of a Giant Left Ventricular Pseudoaneurysm After Mitral Valve Replacement
Kentaro Honda, MDa,*,
Yoshitaka Okamura, MD, PhDa,
Yoshiharu Nishimura, MD, PhDa,
Hiroki Hayashi, MDb
a Department of Thoracic and Cardiovascular Surgery, Wakayama Medical University, Wakayama, Japan
b Department of Thoracic and Cardiovascular Surgery, Minami Wakayama Medical Center, Wakayama, Japan
Accepted for publication October 12, 2010.
* Address correspondence to Dr Honda, Thoracic and Cardiovascular Surgery, Wakayama Medical University, 8110-1 Kimiidera, Wakayama 641-8509, Japan (Email: honda-k{at}wakayama-med.ac.jp).
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Abstract
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Left ventricular pseudoaneurysm (LVP) is a rare cardiac disorder. We describe the repair of a large LVP that was identified in a 73-year-old woman 10 months after she underwent mitral valve replacement for infective endocarditis at another hospital 10 months previously. Follow-up echocardiography showed an enlarged large mass beside the left ventricle, and computed tomography revealed a LVP and an orifice just beside the mitral annulus. We removed the implanted valve and closed the large orifice (35 x 4 mm) using a Xenomedica (Baxter Healthcare Corp, Horw, Switzerland) patch. Computed tomography 3 months later revealed a thrombosed LVP.
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Introduction
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Left ventricular pseudoaneurysm (LVP) is a very rare but lethal complication that can arise after mitral valve replacement (MVR). Several approaches to the repair of LVP have been reported. Here we describe the repair of a large LVP after MVR using Xenomedica patch (Baxter Healthcare Corp, Horw, Switzerland).
A 73-year-old woman was admitted to our hospital on January 16, 2010, with a large mass behind the LV. She had undergone MVR with a Carpentier-Edwards Perimount (CEP; Edwards Lifesciences, Irvine, CA) valve for infective endocarditis of the posterior mitral leaflet 10 months previously. At that time, the posterior mitral annulus was severely calcified, and the left atrial wall at the P2-P3 portion was used to enforce the annulus in the MVR.
The patient's postoperative course was uneventful, and she was discharged 10 days later. Follow-up echocardiography 3 months later revealed a large mass behind the LV, and computed tomography (CT) confirmed that it was a giant LVP. Follow-up CT 6 months later revealed enlargement of the LVP to 11 x 5 x 5 cm and an orifice located just below the mitral annulus (Figs 1
and 2
).
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Fig 1. The preoperative computed tomography showed the large left ventricular (LV) pseudoaneurysm (LVP) and the orifice just beside the mitral annulus (white arrow). (LA = left atrium.)
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Fig 2. The multislice computed tomography image showed the left ventricular pseudoaneurysm (LVP) and its relationship to the coronary artery. (DG = diagonal branch artery; LAD = left anterior descending artery; LCx = left circumflex artery.)
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We planned to repair the LVP on February 9, 2010. We explored the femoral artery and vein before performing a repeat median sternotomy. While investigating the adhesion using a harmonic scalpel (Ultracision, Ethicon S.p.A, Pomezia, Italy), we found a large pulsatile pseudoaneurysm immediately behind the LV.
We established cardiopulmonary bypass and performed a left atriotomy. The implanted CEP valve remained intact, but the orifice of the LVP was unclear when visualized through the CEP valve. We removed the CEP valve and located the orifice (35 x 4 mm) of the LVP just below the mitral annulus (Fig 3
). We closed the orifice using a Xenomedica patch and repeated the MVR using a 25-mm St. Jude Medical mechanical valve (St. Jude Medical Inc, St. Paul, MN).
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Fig 3. In the surgeon's view under left atriotomy, the white arrow points to the orifice of the pseudoaneurysm. (LA = left atrium; LV = left ventricle.)
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Intraoperative echocardiography confirmed the absence of perivalvular leakage but revealed a small residual shunt between the LV and the LVP. Because the amount of the shunt was very small and the LVP cavity was not opened during the procedure, we expected the LVP cavity to become thrombosed and thus completed the operation. The patient was uneventfully weaned from the cardiopulmonary bypass.
Transthoracic echocardiography on postoperative day 7 showed there was no residual shunt and that the LVP was almost completely thrombosed. Computed tomography at 3 months showed that the LVP cavity had disappeared (Fig 4
).
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Fig 4. The postoperative volume-rendered computed tomography image of the heart showrf that the left ventricular pseudoaneurysm disappeared. (LAD = left anterior descending artery; LCx = left circumflex artery; RCA = right coronary artery.)
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Comment
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LV aneurysms that develop late after MVR or coronary artery bypass grafting are rare but lethal complications; however, they can be repaired using various strategies [1–4]. O'Flynn and colleagues [5] described direct closure of an orifice located outside the LV and outside the LV under thoracotomy. We selected median sternotomy for our patient because we considered that the large adhesion in the pericardium that was found at the first operation would cause difficulties with dissecting the heart and finding the orifice through a thoracotomy this time. We easily located the LVP orifice (35 x 4 mm) by the P2, P3 portion after removing the implanted mitral valve.
We initially attempted to close the orifice with an interrupted 4-0 pledgeted Prolene (Ethicon, Somerville, NJ) suture. However, the inferoposterior wall of the LV was not totally explored, and the interrupted suture considerably stressed the LV posterior wall, thus causing a type III LV rupture [6].
We therefore gently fixed a pericardial patch to the LV wall, annulus, and left atrial wall, closed the orifice, and then used the patch as a new annulus for the mitral valve. We implanted a mechanical valve because our patient was 148 cm tall and weighed 42 kg (body surface area, 1.33 m2) and the strut of a bioprosthetic valve might have damaged the LV wall and the suture line of the patch.
During the operation, we did not open the LVP wall because bleeding would have been uncontrollable in the presence of a residual shunt. We considered that if the LVP cavity remained closed, then it should become thrombosed with a small residual shunt. The strategy of keeping the LVP cavity closed and using a mechanical, instead of a bioprosthetic valve, led to repair of the LVP.
The patient can presently walk to our hospital without developing symptoms.
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References
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- Masroor S, Schor J, Carrillo R, Williams DB. Endoventricular pocket repair of type I myocardial rupture after mitral valve replacement: a new technique using pericardial patch, Teflon felt, and BioGlue Ann Thorac Surg 2004;77:1439-1441.[Abstract/Free Full Text]
- Ono M, Wolf RK. Left ventricular pseudoaneurysm late after mitral valve replacement Ann Thorac Surg 2002;73:1303-1305.[Abstract/Free Full Text]
- Yaku H, Shimada Y, Yamada Y, et al. Partial translocation for repair of left ventricular rupture after mitral valve replacement Ann Thorac Surg 2004;78:1851-1853.[Abstract/Free Full Text]
- Kollar A, Byrd 3rd BF, Lui HK, Drinkwater Jr DC. Mitral valve replacement and endocavitary patch repair for a giant left ventricular pseudoaneurysm Ann Thorac Surg 2001;71:2020-2022.[Abstract/Free Full Text]
- O'Flynn E, Purkayastha S, Athanasiou T, Casula R. Repair of a giant left ventricular pseudoaneurysm in a Jehovah's Witness Asian Cardiovasc Thorac Ann 2006;14:328-330.[Abstract/Free Full Text]
- Park CK, Park PW, Yang JH, Lee YT, Sung K, Kim WS. Intraventricular patch repair through an extended aortotomy for repeated left ventricular rupture after mitral valve replacement Ann Thorac Surg 2008;86:1000-1002.[Abstract/Free Full Text]
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Abstract
Introduction
