Post-Traumatic Left Ventricular Outflow Tract Pseudoaneurysm Fei Chen, MD, Shijie Wei, MD, Lian Xiong, MD, and Feng Liu, PhD Department of Thoracic and Cardiovascular Surgery, The Second Xiangya Hospital, Central South University, Hunan, People’s Republic of China
Left ventricular pseudoaneurysm forms when cardiac rupture is contained by adherent or scar tissue. It occurs because of a complication of myocardial infarction, cardiac surgery, and, rarely due to thoracic trauma or infective pericarditis. The locations of a pseudoaneurysm include posterior, lateral, apical, inferior, anterior, and basal, but left ventricular outflow tract is quite rare. We present a case of a left ventricular outflow tract pseudoaneurysm after a blunt chest injury. The patient underwent successful aneurysmorrhaphy. (Ann Thorac Surg 2014;97:311–2) Ó 2014 by The Society of Thoracic Surgeons
L
eft ventricular pseudoaneurysms form when cardiac rupture is contained by adherent pericardium or scar tissue. Most cases of left ventricular pseudoaneurysms were related to myocardial infarction and cardiac surgery [1–8]. We describe a case of a left ventricular outflow tract (LVOT) pseudoaneurysm of a very large size developing from a very small communication just below the aortic valve. It is a very rare occurrence at this location. The patient underwent a successful repair of the pseudoaneurysm by patch closure. A 50-year-old male underwent a medical examination and his heart murmur was noticed a month before being admitted in our hospital. The two-dimensional echocardiography revealed a huge LVOT diverticulum. Then he was transferred to our hospital to seek further treatment. His history included a non-penetrating blunt chest injury when he did carpentry 25 years ago. At that time, he felt slight chest tightness and dizziness and took a rest for 30 minutes in bed. During these 25 years, he has been asymptomatic. On examination, his vitals were normal. A soft systolic murmur was heard over the right sternal edge. In electrocardiography, sinus tachycardia and ST segment elevation were present. The echocardiogram showed a large cystic tumor of 11 8 cm right in front of the
Accepted for publication April 29, 2013. Address correspondence to Dr Liu, Department of Thoracic and Cardiovascular Surgery,The Second Xiangya Hospital, Central South University, No.139 Middle Renmin Rd, Changsha, Hunan 410011, People’s Republic of China; e-mail: [email protected].
Ó 2014 by The Society of Thoracic Surgeons Published by Elsevier Inc
ascending aorta connected by a neck of 13 16 mm to the LVOT. The neck was below the aortic annulus, located in the junction of the right coronary sinus and noncoronary sinus. Doppler echocardiography showed bidirectional flow between the pseudoaneurysm and the left ventricular outflow tract. The ratio of the maximum internal diameter of the orifice to the maximum internal diameter of the cavity was 0.058. A multislice cardiac computerized tomography revealed a large irregular cystic shadow of 12 9 cm (Fig 1A) communicating with the LVOT through a defect below the right coronary sinus (Fig 1B). The right atrium and superior vena cava were obviously compressed. Angiography revealed an abnormal channel of 7-mm diameter below the right coronary sinus to a cystic tumor of 12 9 7cm. The operation was performed using cardiopulmonary bypass instituted by femoral arterial and venous cannulation with antegrade blood cardioplegia. Pericardial adhesiolysis was done. The aneurysm was located close to the right side of the ascending aorta, above the superior vena vein and right atrial appendage. The aneurysm was entered and no thrombi were found. The aneurysm wall was extensively calcified and a 7-mm diameter “neck” of the aneurysm in the LVOT wall was visualized (Fig 2A). Then, a patch of Teflon felt combined with bovine pericardium was sutured by everted horizontal mattress sutures (Ti-cron, Covidien, Mansfield, MA) and reinforced by a single running suture of 4-0 Prolene (Ethicon, Somerville, NJ) (Fig 2B). The patient was easily weaned off bypass and discharged from hospital on postoperative day 7. Histopathologic examination revealed that the aneurysm wall was lined by fibrocollagenous and calcified tissue. No cardiac muscle was seen in the section. Echocardiography before discharge revealed a normal cardiac function.
Comment Left ventricular pseudoaneurysm (LVP) occurs as a complication of myocardial infarction or after cardiac surgery. However, there are several cases of LVP formation after penetrating injuries, closed thoracic trauma, infective pericarditis, and iatrogenically. A review of LVP indicated that 7% of LVP resulted from trauma, in which blunt trauma accounted for 2%. The possible mechanisms of pseudoaneurysm formation after chest injury include a contusion of the myocardial wall, a coronary artery lesion leading to ischemic necrosis, and intramyocardial dissecting hematoma. The symptoms frequently reported are congestive heart failure, chest pain, and dyspnea, but approximately 12% of patients are asymptomatic at the time of diagnosis. The patients with LVP resulting from chest injury, who often have a normal cardial function, are more likely to be asymptomatic. Imaging examination is necessary to differentiate a pseudoaneurysm from a true aneurysm. The ratio of the maximum internal diameter of the orifice to the 0003-4975/$36.00 http://dx.doi.org/10.1016/j.athoracsur.2013.04.137
FEATURE ARTICLES
CASE REPORTS
312
CASE REPORT CHEN ET AL POST-TRAUMATIC LVOT PSEUDOANEURYSM
Ann Thorac Surg 2014;97:311–2
Fig 1. The computed tomographic scan shows (A) the large (12.18 9.17 cm) pseudoaneurysm with its communication with (B) the left ventricular outflow tract. (An ¼ aneurysm; LV ¼ left ventricle.)
FEATURE ARTICLES
Fig 2. Intraoperative photograph showing (A) an opened pseudoaneurysm sac with the “neck” of the aneurysm and (B) the closed neck of the aneurysm with a patch of Teflon felt combined with bovine pericardium.
maximum internal diameter of the cavity never exceeded 0.5 in the cases of a pseudoaneurysm, while this was between 0.9 and 1.0 in the cases of a true aneurysm. This finding was present in our case also. Multislice computed tomography and angiography are also useful to detect a pseudoaneurysm. Posterior pseudoaneurysms are more than twice as common as anterior pseudoaneurysms. Other common locations were the lateral wall, apex, and inferior wall; in this report, the location was the LVOT. It is a very rare occurrence at this location after blunt chest trauma. Surgical interventions are more recommended, for untreated pseudoaneurysms have a 30% to 45% risk of rupture. The surgical repair of post-traumatic LVP has a reported mortality above 7%. To preserve the correct shape or to avoid distortion of the coronary sinus, in most post-traumatic LVP the direct primary suture repair is an effective approach. In our case, the “neck” was just 2-mm below the aortic annulus; operative procedure and exposure of the operative field from the inner side of the LVOT was quite difficult. In order to avoid damage of the aortic valve, we performed the repair from outside of the aorta. In conclusion we report an unusual case of a posttraumatic LVOT pseudoaneurysm. After blunt chest trauma, echocardiography should be used to exclude structural damage, even if the patient is asymptomatic.
A pseudoaneurysm effectively.
can
be
repaired
safely
and
References 1. Adalia R, Sabater L, Azqueta M, et al. Combined left ventricular aneurysm and thoracic aortic pseudoaneurysm caused by blunt chest trauma. J Thorac Cardiovasc Surg 1999;117: 1219–21. 2. Frances C, Romero A, Grady D. Left ventricular pseudoaneurysm. J Am Coll Cardiol 1998;32:557–61. 3. Ribeiro A, Costeira A, Fernandes F, Sim~ oes A, Ara ujo AO, Rodrigues P. Differential imaging diagnosis of left ventricular aneurysm and pseudoaneurysm in the course of a myocardial infarct. [Article in Portuguese] Rev Port Cardiol 1998;17: 535–41. 4. Yeo TC, Malouf JF, Oh JK, Seward JB. Clinical profile and outcome in 52 patients with cardiac pseudoaneurysm. Ann Intern Med 1998;128:299–305. 5. Stewart S, Huddle R, Stuard I, Schreiner BF, DeWeese JA. False aneurysm and pseudo-false aneurysm of the left ventricle: etiology, pathology, diagnosis, and operative management. Ann Thorac Surg 1981;31:259–65. 6. Min HK, Kang do K, Jun HJ, et al. Late simultaneous presentation of left ventricular pseudoaneurysm and tricuspid regurgitation after blunt chest trauma. J Korean Med Sci 2012;27:443–5. 7. Singh S, Puri A, Narain V, Sahni J. Post-traumatic left ventricular pseudoaneurysm. Interact Cardiovasc Thorac Surg 2012;14:359–61. 8. Kang LM, Zhang J, Fan CM, et al. Traumatic left ventricular pseudoaneurysm. Chin Med J (Engl) 2009;122:758–60.
Left ventricular pseudoaneurysm forms when cardiac rupture is contained by adherent or scar tissue. It occurs because of a complication of myocardial infarction, cardiac surgery, and, rarely due to thoracic trauma or infective pericarditis. The locations of a pseudoaneurysm include posterior, lateral, apical, inferior, anterior, and basal, but left ventricular outflow tract is quite rare. We present a case of a left ventricular outflow tract pseudoaneurysm after a blunt chest injury. The patient underwent successful aneurysmorrhaphy. (Ann Thorac Surg 2014;97:311–2) Ó 2014 by The Society of Thoracic Surgeons
L
eft ventricular pseudoaneurysms form when cardiac rupture is contained by adherent pericardium or scar tissue. Most cases of left ventricular pseudoaneurysms were related to myocardial infarction and cardiac surgery [1–8]. We describe a case of a left ventricular outflow tract (LVOT) pseudoaneurysm of a very large size developing from a very small communication just below the aortic valve. It is a very rare occurrence at this location. The patient underwent a successful repair of the pseudoaneurysm by patch closure. A 50-year-old male underwent a medical examination and his heart murmur was noticed a month before being admitted in our hospital. The two-dimensional echocardiography revealed a huge LVOT diverticulum. Then he was transferred to our hospital to seek further treatment. His history included a non-penetrating blunt chest injury when he did carpentry 25 years ago. At that time, he felt slight chest tightness and dizziness and took a rest for 30 minutes in bed. During these 25 years, he has been asymptomatic. On examination, his vitals were normal. A soft systolic murmur was heard over the right sternal edge. In electrocardiography, sinus tachycardia and ST segment elevation were present. The echocardiogram showed a large cystic tumor of 11 8 cm right in front of the
Accepted for publication April 29, 2013. Address correspondence to Dr Liu, Department of Thoracic and Cardiovascular Surgery,The Second Xiangya Hospital, Central South University, No.139 Middle Renmin Rd, Changsha, Hunan 410011, People’s Republic of China; e-mail: [email protected].
Ó 2014 by The Society of Thoracic Surgeons Published by Elsevier Inc
ascending aorta connected by a neck of 13 16 mm to the LVOT. The neck was below the aortic annulus, located in the junction of the right coronary sinus and noncoronary sinus. Doppler echocardiography showed bidirectional flow between the pseudoaneurysm and the left ventricular outflow tract. The ratio of the maximum internal diameter of the orifice to the maximum internal diameter of the cavity was 0.058. A multislice cardiac computerized tomography revealed a large irregular cystic shadow of 12 9 cm (Fig 1A) communicating with the LVOT through a defect below the right coronary sinus (Fig 1B). The right atrium and superior vena cava were obviously compressed. Angiography revealed an abnormal channel of 7-mm diameter below the right coronary sinus to a cystic tumor of 12 9 7cm. The operation was performed using cardiopulmonary bypass instituted by femoral arterial and venous cannulation with antegrade blood cardioplegia. Pericardial adhesiolysis was done. The aneurysm was located close to the right side of the ascending aorta, above the superior vena vein and right atrial appendage. The aneurysm was entered and no thrombi were found. The aneurysm wall was extensively calcified and a 7-mm diameter “neck” of the aneurysm in the LVOT wall was visualized (Fig 2A). Then, a patch of Teflon felt combined with bovine pericardium was sutured by everted horizontal mattress sutures (Ti-cron, Covidien, Mansfield, MA) and reinforced by a single running suture of 4-0 Prolene (Ethicon, Somerville, NJ) (Fig 2B). The patient was easily weaned off bypass and discharged from hospital on postoperative day 7. Histopathologic examination revealed that the aneurysm wall was lined by fibrocollagenous and calcified tissue. No cardiac muscle was seen in the section. Echocardiography before discharge revealed a normal cardiac function.
Comment Left ventricular pseudoaneurysm (LVP) occurs as a complication of myocardial infarction or after cardiac surgery. However, there are several cases of LVP formation after penetrating injuries, closed thoracic trauma, infective pericarditis, and iatrogenically. A review of LVP indicated that 7% of LVP resulted from trauma, in which blunt trauma accounted for 2%. The possible mechanisms of pseudoaneurysm formation after chest injury include a contusion of the myocardial wall, a coronary artery lesion leading to ischemic necrosis, and intramyocardial dissecting hematoma. The symptoms frequently reported are congestive heart failure, chest pain, and dyspnea, but approximately 12% of patients are asymptomatic at the time of diagnosis. The patients with LVP resulting from chest injury, who often have a normal cardial function, are more likely to be asymptomatic. Imaging examination is necessary to differentiate a pseudoaneurysm from a true aneurysm. The ratio of the maximum internal diameter of the orifice to the 0003-4975/$36.00 http://dx.doi.org/10.1016/j.athoracsur.2013.04.137
FEATURE ARTICLES
CASE REPORTS
312
CASE REPORT CHEN ET AL POST-TRAUMATIC LVOT PSEUDOANEURYSM
Ann Thorac Surg 2014;97:311–2
Fig 1. The computed tomographic scan shows (A) the large (12.18 9.17 cm) pseudoaneurysm with its communication with (B) the left ventricular outflow tract. (An ¼ aneurysm; LV ¼ left ventricle.)
FEATURE ARTICLES
Fig 2. Intraoperative photograph showing (A) an opened pseudoaneurysm sac with the “neck” of the aneurysm and (B) the closed neck of the aneurysm with a patch of Teflon felt combined with bovine pericardium.
maximum internal diameter of the cavity never exceeded 0.5 in the cases of a pseudoaneurysm, while this was between 0.9 and 1.0 in the cases of a true aneurysm. This finding was present in our case also. Multislice computed tomography and angiography are also useful to detect a pseudoaneurysm. Posterior pseudoaneurysms are more than twice as common as anterior pseudoaneurysms. Other common locations were the lateral wall, apex, and inferior wall; in this report, the location was the LVOT. It is a very rare occurrence at this location after blunt chest trauma. Surgical interventions are more recommended, for untreated pseudoaneurysms have a 30% to 45% risk of rupture. The surgical repair of post-traumatic LVP has a reported mortality above 7%. To preserve the correct shape or to avoid distortion of the coronary sinus, in most post-traumatic LVP the direct primary suture repair is an effective approach. In our case, the “neck” was just 2-mm below the aortic annulus; operative procedure and exposure of the operative field from the inner side of the LVOT was quite difficult. In order to avoid damage of the aortic valve, we performed the repair from outside of the aorta. In conclusion we report an unusual case of a posttraumatic LVOT pseudoaneurysm. After blunt chest trauma, echocardiography should be used to exclude structural damage, even if the patient is asymptomatic.
A pseudoaneurysm effectively.
can
be
repaired
safely
and
References 1. Adalia R, Sabater L, Azqueta M, et al. Combined left ventricular aneurysm and thoracic aortic pseudoaneurysm caused by blunt chest trauma. J Thorac Cardiovasc Surg 1999;117: 1219–21. 2. Frances C, Romero A, Grady D. Left ventricular pseudoaneurysm. J Am Coll Cardiol 1998;32:557–61. 3. Ribeiro A, Costeira A, Fernandes F, Sim~ oes A, Ara ujo AO, Rodrigues P. Differential imaging diagnosis of left ventricular aneurysm and pseudoaneurysm in the course of a myocardial infarct. [Article in Portuguese] Rev Port Cardiol 1998;17: 535–41. 4. Yeo TC, Malouf JF, Oh JK, Seward JB. Clinical profile and outcome in 52 patients with cardiac pseudoaneurysm. Ann Intern Med 1998;128:299–305. 5. Stewart S, Huddle R, Stuard I, Schreiner BF, DeWeese JA. False aneurysm and pseudo-false aneurysm of the left ventricle: etiology, pathology, diagnosis, and operative management. Ann Thorac Surg 1981;31:259–65. 6. Min HK, Kang do K, Jun HJ, et al. Late simultaneous presentation of left ventricular pseudoaneurysm and tricuspid regurgitation after blunt chest trauma. J Korean Med Sci 2012;27:443–5. 7. Singh S, Puri A, Narain V, Sahni J. Post-traumatic left ventricular pseudoaneurysm. Interact Cardiovasc Thorac Surg 2012;14:359–61. 8. Kang LM, Zhang J, Fan CM, et al. Traumatic left ventricular pseudoaneurysm. Chin Med J (Engl) 2009;122:758–60.
