Left Ventricular Pseudoaneurysm Associated With Mitral Regurgitation M. Aziz Ezzat, MD, Ibrahim Abdelmeguid, MD, Didier Leclerc, MD, Alix Nguyen, MD, and Armand Piwnica, MD Service de Chirurgie Cardiovasculaire, Hbpital Lanboisiere, Pans, France
A patient with a large posterolateral left ventricular pseudoaneurysm flush with the posterior papillary muscle and associated with mitral regurgitation was successfully treated surgically. The operation consisted of opening the sac of the aneurysm, dissecting the wall of the left ventricle from the fibrous wall of the sac, leaving a cuff of fibrous tissue suitable to hold sutures, and closing the defect with a Dacron patch. (Ann Thorac Surg 1992;53:5044)
A
left ventricular pseudoaneurysm develops after acute rupture of an infarcted area of the left ventricle. Such ruptures are usually fatal, but when the pericardium is sufficiently adherent to the epicardium, the rupture may result in a localized hemopericardium. The persistent communication of the hemopericardium with the left ventricular cavity results in gradual expansion of the hemopericardium into a large false aneurysm, the wall of which is composed of pericardium and adhesions and the mouth of which is usually narrow. Such aneurysms have a strong tendency to rupture, and therefore surgical resection with or without coronary revascularization is usually advisable [l]. This is in contrast to true left ventricular aneurysms, in which the risk of rupture is very rare; therefore, the presence of a true left ventricular aneurysm per se is not considered an indication for operation. A 60-year-old man who was a heavy cigarette smoker and had chronic bronchitis and a history of hypertension was urgently hospitalized on July 1, 1990, with supraventricular tachycardia, severe systemic hypertension (200/110 mm Hg), and acute pulmonary edema. An urgent medical treatment in the coronary care unit succeeded in controlling the situation. An echocardiographic study done on the same day showed a localized pericardial effusion below the left ventricle. On July 4, 1990, the general condition deteriorated Accepted for publication Aug 5, 1991 Presented at the Problem Case Seminar at the Twenty-Seventh Annual Meeting of The Society of Thoracic Surgeons, San Francisco, CA, Feb 1MO,1991. Address reprint requests to Dr Ezzat, c/o Dr Piwnica, Service de Chirurgie Cardiovasculaire, Hapital Lariboisihre, 2 rue Ambroise, Pare, 75010 Paris, France.
0 1992 by The Society of Thoracic Surgeons
again, dyspnea increased, and orthopnea developed. A chest roentgenogram showed evidence of pulmonary congestion and a huge cardiomegaly. Electrocardiography showed nonspecific ST segment and T wave changes opposite to the lateral wall of the left ventricle. Doppler echocardiography showed a large cavity containing fluid communicating with the left ventricle and compressing the left atrium. The diagnosis of a false aneurysm of the left ventricle was considered. The patient was transferred from Algeria to Paris and arrived at our hospital on July 12, 1990. An echocardiographic study (Figs 1,2) confirmed the presence of a large false aneurysm (6 cm x 3 cm) situated posterolateral to the left ventricle and communicating with the left ventricular cavity. The mouth of the false aneurysm was between the posterior papillary muscle and the ring of the mitral valve. Left ventriculography showed a large posterolatera1 sac that communicated freely with the cavity of the left ventricle. The anterior wall of the left ventricle and the interventricular septum moved normally, whereas the posterior wall showed marked hypokinesia. There was mild to moderate mitral insufficiency. Coronary angiography showed a normal left anterior descending coronary artery system and normal right coronary artery system, whereas the main circumflex artery was totally occluded after giving off a long, high lateral branch. The patient was scheduled for an urgent operation for resection of this aneurysm. The left femoral artery was exposed ”just in case” but not cannulated. Median sternotomy was done safely, and cardiopulmonary bypass was established as usual through the ascending aorta and the two venae cavae. A left ventricular vent was put through the right superior pulmonary vein. Myocardial protection was afforded by cold crystalloid cardioplegia supplemented by moderate hypothermia and topical cooling. Dissection of intrapericardial adhesions over the left ventricle allowed the visualization of a large sac about 10 cm in diameter situated posterolateral to the left ventricle. The sac was opened and found devoid of any thrombi or blood clots and freely communicating with the cavity of the left ventricle through a big oval hole about 3 cm x 2 cm situated lateral to and flush with the posterior papillary muscle of the left ventricle. The posterior papillary muscle and its chordae were well exposed through the defect (Fig 3). There were two choices as regards the method of 0003-4975/92/$5.00
CASE REPORT EZZAT ET AL LV PSEUDOANEURYSM
Ann Thorac Surg 1992;53:5044
Fig 1 . Two-dimensional echocardiographic picture showing the aneuy s m (AN) compressing the leff atrium (LA) and communicating freely with the left ventricular cavity (LV) by a wide orifice. (MV = mitral valve.)
closure of this defect, either to close it directly with the risk of changing the papillary muscle-chordal axis of the mitral valve and aggravating the degree of mitral incompetence or to close it with a patch, which will form a relatively big akinetic area. We preferred the second choice, and a patch of Dacron (4 cm x 3 cm) was used and sutured in place by a series of interrupted sutures of 4-0 Prolene with Teflon pledgets and reinforced by another layer of continuous suture of 4-0 Prolene. Weaning from bypass necessitated the use of intraaortic balloon counterpulsation and dobutamine hydrochloride (Dobutrex; Eli Lilly and Co, Indianapolis, IN). Hemostasis was difficult as there was bleeding from the wall of the false aneurysm. In the intensive care unit the patient was in excellent hemodynamic condition with a cardiac index of 3 L * min-’ m-’ on the balloon counterpulsation and the
505
Fig 3 . Operative picture showing the wide orifice of the aneurysm and the close relationship with the mitral valve apparatus.
dobutamine. Continuous bleeding persisted throughout the first night but it did not affect the hemodynamic status of the patient. The next morning, the patient was reopened and we found that bleeding came from the posterior aspect of the left ventricle from a solitary point at the suture line of the patch. This was not accessible without the use of extracorporeal circulation. Two interrupted sutures of Prolene with Teflon pledgets succeeded in stopping the bleeding. The patient was weaned again from bypass by balloon counterpulsation and dobutamine. In the intensive care unit the patient’s condition was excellent both hemodynamically and hemostatically. Two days later the patient was extubated with a good hemodynamic profile without the balloon and the inotropic support. On the fifth day, the patient was transferred from the intensive care unit to the ward, and 2 weeks later he went back to Algeria in good condition.
Comment
Fig 2 . Echocardiographic picture showing the close relationship of the posterior papillary muscle and chordae (CH) of the mitral valve (MV) with the mouth of the aneurysm (AN). (LA = left atrium; LV = left ventricle.)
This large pseudoaneurysm with its thick fibrous wall cannot develop in a 2-week period. We believe that there was an old attack of myocardial infarction that passed smoothly and resulted in the formation of such a huge aneurysm. Probably the acute pulmonary edema that had occurred on July 1 resulted from the rhythm disturbance and the hypertension. The mild to moderate degree of mitral regurgitation that was present preoperatively was probably of an ischemic nature, but another important mechanism in this case was the lack of proper shortening of the longitudinal axis of the left ventricle during systole due to the discontinuity of the outer longitudinal muscle layer of the left ventricle over a big area that corresponds to the defect and the close proximity between the defect and the posterior papillary muscle.
506
Ann Thorac Surg 1992;535044
CASE REPORT EZZAT ET AL LV PSEUDOANEURYSM
We found no increase in the degree of mitral regurgitation after operation, and we believe that our choice of closing the defect by using a patch was correct as the other choice of direct closure of the defect by edge to edge probably would aggravate the degree of mitral regurgitation. We also believe that a concomitant mitral valve procedure, as described in other reports [2], increases hospital mortality.
References 1. Kirklin J,Barratt-BoyesB. False left ventricular aneurysms.In: Kirklin J, Barratt-Boyes 8, eds. Cardiac surgery. New York Wiley and Sons, 1986296. 2. Olearchyk AS, Lemole GM, Spagna PM. Left ventricular aneurysm: ten years experience in surgical treatment of 244 cases: improved clinical status, haemodynamics and long term longevity. J Thorac Cardiovasc Surg 1984;88:54453.
Notice From the American Board of Thoracic Surgery The part 1 (written) examination will be held at the HyattTx*On FebruFort worth ary 7, 1993. The closing date for registration is August 1, 1992. examination, a To be admissible for the part II candidate must have successfully completed the part I (written) examination.
A candidate applying for admission to the certifying examination must fulfill all the requirements of the board in force at the time the application is received. Please address all communications to the American Board of Thoracic Surgery, One Rotary Center, Suite 803, Evanston, IL 60201.
A patient with a large posterolateral left ventricular pseudoaneurysm flush with the posterior papillary muscle and associated with mitral regurgitation was successfully treated surgically. The operation consisted of opening the sac of the aneurysm, dissecting the wall of the left ventricle from the fibrous wall of the sac, leaving a cuff of fibrous tissue suitable to hold sutures, and closing the defect with a Dacron patch. (Ann Thorac Surg 1992;53:5044)
A
left ventricular pseudoaneurysm develops after acute rupture of an infarcted area of the left ventricle. Such ruptures are usually fatal, but when the pericardium is sufficiently adherent to the epicardium, the rupture may result in a localized hemopericardium. The persistent communication of the hemopericardium with the left ventricular cavity results in gradual expansion of the hemopericardium into a large false aneurysm, the wall of which is composed of pericardium and adhesions and the mouth of which is usually narrow. Such aneurysms have a strong tendency to rupture, and therefore surgical resection with or without coronary revascularization is usually advisable [l]. This is in contrast to true left ventricular aneurysms, in which the risk of rupture is very rare; therefore, the presence of a true left ventricular aneurysm per se is not considered an indication for operation. A 60-year-old man who was a heavy cigarette smoker and had chronic bronchitis and a history of hypertension was urgently hospitalized on July 1, 1990, with supraventricular tachycardia, severe systemic hypertension (200/110 mm Hg), and acute pulmonary edema. An urgent medical treatment in the coronary care unit succeeded in controlling the situation. An echocardiographic study done on the same day showed a localized pericardial effusion below the left ventricle. On July 4, 1990, the general condition deteriorated Accepted for publication Aug 5, 1991 Presented at the Problem Case Seminar at the Twenty-Seventh Annual Meeting of The Society of Thoracic Surgeons, San Francisco, CA, Feb 1MO,1991. Address reprint requests to Dr Ezzat, c/o Dr Piwnica, Service de Chirurgie Cardiovasculaire, Hapital Lariboisihre, 2 rue Ambroise, Pare, 75010 Paris, France.
0 1992 by The Society of Thoracic Surgeons
again, dyspnea increased, and orthopnea developed. A chest roentgenogram showed evidence of pulmonary congestion and a huge cardiomegaly. Electrocardiography showed nonspecific ST segment and T wave changes opposite to the lateral wall of the left ventricle. Doppler echocardiography showed a large cavity containing fluid communicating with the left ventricle and compressing the left atrium. The diagnosis of a false aneurysm of the left ventricle was considered. The patient was transferred from Algeria to Paris and arrived at our hospital on July 12, 1990. An echocardiographic study (Figs 1,2) confirmed the presence of a large false aneurysm (6 cm x 3 cm) situated posterolateral to the left ventricle and communicating with the left ventricular cavity. The mouth of the false aneurysm was between the posterior papillary muscle and the ring of the mitral valve. Left ventriculography showed a large posterolatera1 sac that communicated freely with the cavity of the left ventricle. The anterior wall of the left ventricle and the interventricular septum moved normally, whereas the posterior wall showed marked hypokinesia. There was mild to moderate mitral insufficiency. Coronary angiography showed a normal left anterior descending coronary artery system and normal right coronary artery system, whereas the main circumflex artery was totally occluded after giving off a long, high lateral branch. The patient was scheduled for an urgent operation for resection of this aneurysm. The left femoral artery was exposed ”just in case” but not cannulated. Median sternotomy was done safely, and cardiopulmonary bypass was established as usual through the ascending aorta and the two venae cavae. A left ventricular vent was put through the right superior pulmonary vein. Myocardial protection was afforded by cold crystalloid cardioplegia supplemented by moderate hypothermia and topical cooling. Dissection of intrapericardial adhesions over the left ventricle allowed the visualization of a large sac about 10 cm in diameter situated posterolateral to the left ventricle. The sac was opened and found devoid of any thrombi or blood clots and freely communicating with the cavity of the left ventricle through a big oval hole about 3 cm x 2 cm situated lateral to and flush with the posterior papillary muscle of the left ventricle. The posterior papillary muscle and its chordae were well exposed through the defect (Fig 3). There were two choices as regards the method of 0003-4975/92/$5.00
CASE REPORT EZZAT ET AL LV PSEUDOANEURYSM
Ann Thorac Surg 1992;53:5044
Fig 1 . Two-dimensional echocardiographic picture showing the aneuy s m (AN) compressing the leff atrium (LA) and communicating freely with the left ventricular cavity (LV) by a wide orifice. (MV = mitral valve.)
closure of this defect, either to close it directly with the risk of changing the papillary muscle-chordal axis of the mitral valve and aggravating the degree of mitral incompetence or to close it with a patch, which will form a relatively big akinetic area. We preferred the second choice, and a patch of Dacron (4 cm x 3 cm) was used and sutured in place by a series of interrupted sutures of 4-0 Prolene with Teflon pledgets and reinforced by another layer of continuous suture of 4-0 Prolene. Weaning from bypass necessitated the use of intraaortic balloon counterpulsation and dobutamine hydrochloride (Dobutrex; Eli Lilly and Co, Indianapolis, IN). Hemostasis was difficult as there was bleeding from the wall of the false aneurysm. In the intensive care unit the patient was in excellent hemodynamic condition with a cardiac index of 3 L * min-’ m-’ on the balloon counterpulsation and the
505
Fig 3 . Operative picture showing the wide orifice of the aneurysm and the close relationship with the mitral valve apparatus.
dobutamine. Continuous bleeding persisted throughout the first night but it did not affect the hemodynamic status of the patient. The next morning, the patient was reopened and we found that bleeding came from the posterior aspect of the left ventricle from a solitary point at the suture line of the patch. This was not accessible without the use of extracorporeal circulation. Two interrupted sutures of Prolene with Teflon pledgets succeeded in stopping the bleeding. The patient was weaned again from bypass by balloon counterpulsation and dobutamine. In the intensive care unit the patient’s condition was excellent both hemodynamically and hemostatically. Two days later the patient was extubated with a good hemodynamic profile without the balloon and the inotropic support. On the fifth day, the patient was transferred from the intensive care unit to the ward, and 2 weeks later he went back to Algeria in good condition.
Comment
Fig 2 . Echocardiographic picture showing the close relationship of the posterior papillary muscle and chordae (CH) of the mitral valve (MV) with the mouth of the aneurysm (AN). (LA = left atrium; LV = left ventricle.)
This large pseudoaneurysm with its thick fibrous wall cannot develop in a 2-week period. We believe that there was an old attack of myocardial infarction that passed smoothly and resulted in the formation of such a huge aneurysm. Probably the acute pulmonary edema that had occurred on July 1 resulted from the rhythm disturbance and the hypertension. The mild to moderate degree of mitral regurgitation that was present preoperatively was probably of an ischemic nature, but another important mechanism in this case was the lack of proper shortening of the longitudinal axis of the left ventricle during systole due to the discontinuity of the outer longitudinal muscle layer of the left ventricle over a big area that corresponds to the defect and the close proximity between the defect and the posterior papillary muscle.
506
Ann Thorac Surg 1992;535044
CASE REPORT EZZAT ET AL LV PSEUDOANEURYSM
We found no increase in the degree of mitral regurgitation after operation, and we believe that our choice of closing the defect by using a patch was correct as the other choice of direct closure of the defect by edge to edge probably would aggravate the degree of mitral regurgitation. We also believe that a concomitant mitral valve procedure, as described in other reports [2], increases hospital mortality.
References 1. Kirklin J,Barratt-BoyesB. False left ventricular aneurysms.In: Kirklin J, Barratt-Boyes 8, eds. Cardiac surgery. New York Wiley and Sons, 1986296. 2. Olearchyk AS, Lemole GM, Spagna PM. Left ventricular aneurysm: ten years experience in surgical treatment of 244 cases: improved clinical status, haemodynamics and long term longevity. J Thorac Cardiovasc Surg 1984;88:54453.
Notice From the American Board of Thoracic Surgery The part 1 (written) examination will be held at the HyattTx*On FebruFort worth ary 7, 1993. The closing date for registration is August 1, 1992. examination, a To be admissible for the part II candidate must have successfully completed the part I (written) examination.
A candidate applying for admission to the certifying examination must fulfill all the requirements of the board in force at the time the application is received. Please address all communications to the American Board of Thoracic Surgery, One Rotary Center, Suite 803, Evanston, IL 60201.
