HLC 1658 No. of Pages 3
CLINICAL SPOTLIGHT
Heart, Lung and Circulation (2014) xx, 1–3 1443-9506/04/$36.00 http://dx.doi.org/10.1016/j.hlc.2014.07.069
Ruptured Left Ventricular False Aneurysm following Acute Myocardial Infarction: Case Report and Review of the Literature Claudia Villanueva, MBBS a,b*, David Milder, MD a, Con Manganas, FRACS a a
Cardiac Surgery Unit, St George Hospital, Kogarah University of New South Wales, Australia
b
Received 10 June 2014; received in revised form 18 July 2014; accepted 23 July 2014; online published-ahead-of-print xxx
False aneurysms of the left ventricle complicating acute myocardial infarction are rare. Given they are only contained by pericardial adhesions, they are prone to rupture and hence surgical repair is mandatory. We report a successful repair of a ruptured false aneurysm and then briefly review the current literature.
Introduction Left ventricular free wall rupture following myocardial infarction is usually fatal. Rarely, the rupture is contained by adherent pericardium, resulting in the formation of a potentially unstable false aneurysm which is prone to rupture.
Case Report A 65 year-old previously healthy male presented to the emergency department following the acute onset of chest pain radiating to the left shoulder, associated with pre-syncope. He was in shock with a systolic pressure of 80 mmHg. An urgent bedside transthoracic echocardiogram (TTE) demonstrated a 5x4 cm aneurysm involving the lateral and inferior walls of the left ventricle, associated with a large global pericardial effusion and features of cardiac tamponade (Figure 1). Emergency surgery was performed and a large haemopericardium was drained, revealing a large aneurysmal sac of the posterior lateral left ventricular wall, associated with a pinpoint rupture spot. Cardiopulmonary bypass was instituted with standard antegrade cardioplegic arrest and mild systemic hypothermia. Left ventriculotomy through the aneurysmal sac was then performed, revealing an isolated left ventricular free wall defect extending from the endocardium and communicating with the ruptured false aneurysm (Figure 2). Part of the
aneurysmal sac sent for histopathology was reported as thrombus. The defect was excluded with a PTFE (polytetrafluoroethylene) endoventricular patch and continuous 4/0 prolene sutures. The ventriculotomy was closed by plication technique with a Teflon 1 reinforced two-layer suture line. A repeat TTE day 3 post-operatively showed two small shunts at the proximal and distal attachment points of the patch, with a small residual cavity between the endoventricular patch and the ventriculotomy site. An angiogram performed postoperatively showed an occluded second right posterolateral branch of the right coronary artery, the likely anatomical culprit lesion for this presumed ischaemic false aneurysm (Figure 3). The patient was discharged day 6 post-operatively, and underwent a full clinical recovery. At six weeks, he had recovered complete functional capacity and an echocardiogram showed no evidence of residual aneurysm formation.
Discussion The incidence of false aneurysm is low. Csapo et al in 2009 reported an incidence of 0.23% [1]. The most common cause of false aneurysm formation is myocardial infarction, likely to have occurred in our patient based on the angiographic findings. Other causes include previous cardiac surgery, trauma and localised infection [2]. False aneurysms are typically located on the posterior or lateral wall of the left ventricle,
*Corresponding author. St George Hospital, Gray St, Kogarah, 2217. Tel.: +61 2 91131111, Email: [email protected] © 2014 Australian and New Zealand Society of Cardiac and Thoracic Surgeons (ANZSCTS) and the Cardiac Society of Australia and New Zealand (CSANZ). Published by Elsevier Inc. All rights reserved.
Please cite this article in press as: Villanueva C, et al. Ruptured Left Ventricular False Aneurysm following Acute Myocardial Infarction: Case Report and Review of the Literature. Heart, Lung and Circulation (2014), http://dx.doi.org/10.1016/j. hlc.2014.07.069
HLC 1658 No. of Pages 3
2
C. Villanueva et al.
Figure 3 Post-operative coronary angiogram demonstrating an occluded right postero-lateral branch of the right coronary artery. Figure 1 Bedside TTE revealing an aneurysm involving the lateral and inferior wall of the left ventricle, haemopericardium and compression of the adjacent right ventricle.
whereas true aneurysms are typically located anteriorly [2,3]. Rupture of the ventricular wall typically occurs three to five days after myocardial infarction [4]; yet, the median time to diagnosis is typically four months after infarction [2] with the
Figure 2 Intra-operative photo showing large ventricular aneurysm with forceps over pinpoint site of rupture.
diagnosis being an incidental finding. Perhaps this is because the clinical presentations of false aneurysms are non-specific and vary, but include congestive heart failure, angina, arrhythmias, syncopal episodes and thromboembolic events. There is no clear consistency in the literature regarding rates of rupture. Pseudoaneurysms have a high propensity to rupture which may occur between 10 days and three months reported as high as 44% in a small series [5] to 50% at two years in others and thus definite surgical management is mandatory [1]. However, for chronic pseudoaneurysms there is no clear consensus regarding the indication for surgery. Some argue for conservative measures unless there are symptoms while others advocate surgical repair due to the uncertainty surrounding the natural history of the false aneurysms [6]. Moreno et al followed up nine patients managed conservatively due to their surgical unsuitability for a mean period of 3.8 years and although mortality was high at 26%, no deaths were attributable to rupture. They concluded the risk of fatal rupture in post infarction left ventricular pseudoaneurysms is very low but recommend anticoagulation in these patients due to the high risk of stroke (32.5% at four years) [7]. Surgical repair was first described in 1958 by Cooley and involved a linear repair of the defect. Methods have since evolved, with patch remodelling techniques now being commonly used and considered by some to be more efficacious [8]. Eren et al in their 2007 revision of 14 patients surgically managed pseudoaneurysms, describes two techniques. For chronic pseudoaneurysms the repair was done by direct closure because of its fibrotic edges and reinforced with a Teflon felt and for acute cases, with either synthetic or pericardial patches to cover the defect due to friable necrotic myocardium [6]. Reportedly, post-operative mortality varies (23% to 35.7%), and often is related to the acute phase of myocardial infarction, poor left ventricular function, the need for mitral valve replacement and redo operations [6,9–11]. Controversy remains regarding the role of pre-operative coronary angiography. False aneurysms are typically associated with at
Please cite this article in press as: Villanueva C, et al. Ruptured Left Ventricular False Aneurysm following Acute Myocardial Infarction: Case Report and Review of the Literature. Heart, Lung and Circulation (2014), http://dx.doi.org/10.1016/j. hlc.2014.07.069
HLC 1658 No. of Pages 3 Ruptured Left Ventricular False Aneurysm following Acute Myocardial Infarction
least two-vessel disease, and some advocate angiography to facilitate simultaneous bypass grafting. Survival advantage may be associated with concomitant bypass grafting in selected patient subsets, especially triple vessel and/or significant left main trunk disease [10,12]. Clearly, the risks of pre-operative coronary angiography need to be carefully weighed against the potential benefits. Angiography may not be possible in the haemodynamically unstable patient with ruptured left ventricular false aneurysm.
Conclusion False aneurysms are a rare complication of myocardial infarction and remain a rare diagnosis. A high index of suspicion is required for diagnosis. False aneurysms diagnosed within three months following infarction should proceed to emergency surgical repair due to the relatively high risk of fatal rupture. Excellent clinical and functional recovery may result following surgery. The role of pre-operative coronary angiography in this group of patients remains controversial and warrants careful individual case consideration.
Acknowledgements The authors declare that there is no conflict of interest and no funding was required for this report.
3
References [1] Csapo K, Voith L, Szuk T, Edes I, Kereiakes DJ. Postinfarction left ventricular pseudoaneurysm. Clinical Cardiology 1997;20:898–903. [2] Yeo TC, Malouf JF, Oh JK, Seward JB. Clinical profile and outcome in 52 patients with cardiac pseudoaneurysm. Annals of Internal Medicine 1998;128:299–305. [3] Loop FD, Effler DB, Webster JS, Groves LK. Posterior ventricular aneurysms. Etiologic factors and results of surgical treatment. The New England Journal of Medicine 1973;288:237–9. [4] Bryniarski L, Kubinyi A, Ekiert-Kubinyi M, Kawecka-Jaszcz K. Postinfarction left ventricular pseudoaneurysm with left-to-right shunt: case report and review of the literature. International Journal of Cardiology 2010;139:199–201. [5] Van Tassel RA, Edwards JE. Rupture of heart complicating myocardial infarction. Analysis of 40 cases including nine examples of left ventricular false aneurysm. Chest 1972;61:104–16. [6] Moreno R, Gordillo E, Zamorano J, Almeria C, Garcia-Rubira JC, Fernandez-Ortiz A, Macaya C. Long term outcome of patients with postinfarction left ventricular pseudoaneurysm. Heart 2003;89:1144–6. [7] Eren E, Bozbuga N, Toker ME, Keles C, Rabus MB, et al. Surgical treatment of post-infarction left ventricular pseudoaneurysm: a twodecade experience. Texas Heart Institute Journal 2007;34:47–51. [8] Chen X, Qiu ZB, Xu M, Liu LL, Jiang YS, et al. Surgery for left ventricular aneurysm after myocardial infarction: techniques selection and results assessment. Chinese Medical Journal 2012;125:4373–9. [9] Frances C, Romero A, Grady D. Left ventricular pseudoaneurysm. Journal of the American College of Cardiology 1998;32:557–61. [10] Komeda M, David TE, Malik A, Ivanov J, Sun Z. Operative risks and long-term results of operation for left ventricular aneurysm. Ann Thoracic Surg 1992;53:22–9. [11] Pretre R, Linka A, Jenni R, Turina MI. Surgical treatment of acquired left ventricular pseudoaneurysms. Ann Thorac Surg 2000;70:553–7. [12] Stahle E, Bergstrom R, Nystrom S, Edlund B, Sjorgren I, Holmberg L. Surgical treatment of left ventricular aneurysm – assessment of risk factors for early and late mortality. European Journal of Cardiothoracic Surgery 1994;8:67–73.
Please cite this article in press as: Villanueva C, et al. Ruptured Left Ventricular False Aneurysm following Acute Myocardial Infarction: Case Report and Review of the Literature. Heart, Lung and Circulation (2014), http://dx.doi.org/10.1016/j. hlc.2014.07.069
CLINICAL SPOTLIGHT
Heart, Lung and Circulation (2014) xx, 1–3 1443-9506/04/$36.00 http://dx.doi.org/10.1016/j.hlc.2014.07.069
Ruptured Left Ventricular False Aneurysm following Acute Myocardial Infarction: Case Report and Review of the Literature Claudia Villanueva, MBBS a,b*, David Milder, MD a, Con Manganas, FRACS a a
Cardiac Surgery Unit, St George Hospital, Kogarah University of New South Wales, Australia
b
Received 10 June 2014; received in revised form 18 July 2014; accepted 23 July 2014; online published-ahead-of-print xxx
False aneurysms of the left ventricle complicating acute myocardial infarction are rare. Given they are only contained by pericardial adhesions, they are prone to rupture and hence surgical repair is mandatory. We report a successful repair of a ruptured false aneurysm and then briefly review the current literature.
Introduction Left ventricular free wall rupture following myocardial infarction is usually fatal. Rarely, the rupture is contained by adherent pericardium, resulting in the formation of a potentially unstable false aneurysm which is prone to rupture.
Case Report A 65 year-old previously healthy male presented to the emergency department following the acute onset of chest pain radiating to the left shoulder, associated with pre-syncope. He was in shock with a systolic pressure of 80 mmHg. An urgent bedside transthoracic echocardiogram (TTE) demonstrated a 5x4 cm aneurysm involving the lateral and inferior walls of the left ventricle, associated with a large global pericardial effusion and features of cardiac tamponade (Figure 1). Emergency surgery was performed and a large haemopericardium was drained, revealing a large aneurysmal sac of the posterior lateral left ventricular wall, associated with a pinpoint rupture spot. Cardiopulmonary bypass was instituted with standard antegrade cardioplegic arrest and mild systemic hypothermia. Left ventriculotomy through the aneurysmal sac was then performed, revealing an isolated left ventricular free wall defect extending from the endocardium and communicating with the ruptured false aneurysm (Figure 2). Part of the
aneurysmal sac sent for histopathology was reported as thrombus. The defect was excluded with a PTFE (polytetrafluoroethylene) endoventricular patch and continuous 4/0 prolene sutures. The ventriculotomy was closed by plication technique with a Teflon 1 reinforced two-layer suture line. A repeat TTE day 3 post-operatively showed two small shunts at the proximal and distal attachment points of the patch, with a small residual cavity between the endoventricular patch and the ventriculotomy site. An angiogram performed postoperatively showed an occluded second right posterolateral branch of the right coronary artery, the likely anatomical culprit lesion for this presumed ischaemic false aneurysm (Figure 3). The patient was discharged day 6 post-operatively, and underwent a full clinical recovery. At six weeks, he had recovered complete functional capacity and an echocardiogram showed no evidence of residual aneurysm formation.
Discussion The incidence of false aneurysm is low. Csapo et al in 2009 reported an incidence of 0.23% [1]. The most common cause of false aneurysm formation is myocardial infarction, likely to have occurred in our patient based on the angiographic findings. Other causes include previous cardiac surgery, trauma and localised infection [2]. False aneurysms are typically located on the posterior or lateral wall of the left ventricle,
*Corresponding author. St George Hospital, Gray St, Kogarah, 2217. Tel.: +61 2 91131111, Email: [email protected] © 2014 Australian and New Zealand Society of Cardiac and Thoracic Surgeons (ANZSCTS) and the Cardiac Society of Australia and New Zealand (CSANZ). Published by Elsevier Inc. All rights reserved.
Please cite this article in press as: Villanueva C, et al. Ruptured Left Ventricular False Aneurysm following Acute Myocardial Infarction: Case Report and Review of the Literature. Heart, Lung and Circulation (2014), http://dx.doi.org/10.1016/j. hlc.2014.07.069
HLC 1658 No. of Pages 3
2
C. Villanueva et al.
Figure 3 Post-operative coronary angiogram demonstrating an occluded right postero-lateral branch of the right coronary artery. Figure 1 Bedside TTE revealing an aneurysm involving the lateral and inferior wall of the left ventricle, haemopericardium and compression of the adjacent right ventricle.
whereas true aneurysms are typically located anteriorly [2,3]. Rupture of the ventricular wall typically occurs three to five days after myocardial infarction [4]; yet, the median time to diagnosis is typically four months after infarction [2] with the
Figure 2 Intra-operative photo showing large ventricular aneurysm with forceps over pinpoint site of rupture.
diagnosis being an incidental finding. Perhaps this is because the clinical presentations of false aneurysms are non-specific and vary, but include congestive heart failure, angina, arrhythmias, syncopal episodes and thromboembolic events. There is no clear consistency in the literature regarding rates of rupture. Pseudoaneurysms have a high propensity to rupture which may occur between 10 days and three months reported as high as 44% in a small series [5] to 50% at two years in others and thus definite surgical management is mandatory [1]. However, for chronic pseudoaneurysms there is no clear consensus regarding the indication for surgery. Some argue for conservative measures unless there are symptoms while others advocate surgical repair due to the uncertainty surrounding the natural history of the false aneurysms [6]. Moreno et al followed up nine patients managed conservatively due to their surgical unsuitability for a mean period of 3.8 years and although mortality was high at 26%, no deaths were attributable to rupture. They concluded the risk of fatal rupture in post infarction left ventricular pseudoaneurysms is very low but recommend anticoagulation in these patients due to the high risk of stroke (32.5% at four years) [7]. Surgical repair was first described in 1958 by Cooley and involved a linear repair of the defect. Methods have since evolved, with patch remodelling techniques now being commonly used and considered by some to be more efficacious [8]. Eren et al in their 2007 revision of 14 patients surgically managed pseudoaneurysms, describes two techniques. For chronic pseudoaneurysms the repair was done by direct closure because of its fibrotic edges and reinforced with a Teflon felt and for acute cases, with either synthetic or pericardial patches to cover the defect due to friable necrotic myocardium [6]. Reportedly, post-operative mortality varies (23% to 35.7%), and often is related to the acute phase of myocardial infarction, poor left ventricular function, the need for mitral valve replacement and redo operations [6,9–11]. Controversy remains regarding the role of pre-operative coronary angiography. False aneurysms are typically associated with at
Please cite this article in press as: Villanueva C, et al. Ruptured Left Ventricular False Aneurysm following Acute Myocardial Infarction: Case Report and Review of the Literature. Heart, Lung and Circulation (2014), http://dx.doi.org/10.1016/j. hlc.2014.07.069
HLC 1658 No. of Pages 3 Ruptured Left Ventricular False Aneurysm following Acute Myocardial Infarction
least two-vessel disease, and some advocate angiography to facilitate simultaneous bypass grafting. Survival advantage may be associated with concomitant bypass grafting in selected patient subsets, especially triple vessel and/or significant left main trunk disease [10,12]. Clearly, the risks of pre-operative coronary angiography need to be carefully weighed against the potential benefits. Angiography may not be possible in the haemodynamically unstable patient with ruptured left ventricular false aneurysm.
Conclusion False aneurysms are a rare complication of myocardial infarction and remain a rare diagnosis. A high index of suspicion is required for diagnosis. False aneurysms diagnosed within three months following infarction should proceed to emergency surgical repair due to the relatively high risk of fatal rupture. Excellent clinical and functional recovery may result following surgery. The role of pre-operative coronary angiography in this group of patients remains controversial and warrants careful individual case consideration.
Acknowledgements The authors declare that there is no conflict of interest and no funding was required for this report.
3
References [1] Csapo K, Voith L, Szuk T, Edes I, Kereiakes DJ. Postinfarction left ventricular pseudoaneurysm. Clinical Cardiology 1997;20:898–903. [2] Yeo TC, Malouf JF, Oh JK, Seward JB. Clinical profile and outcome in 52 patients with cardiac pseudoaneurysm. Annals of Internal Medicine 1998;128:299–305. [3] Loop FD, Effler DB, Webster JS, Groves LK. Posterior ventricular aneurysms. Etiologic factors and results of surgical treatment. The New England Journal of Medicine 1973;288:237–9. [4] Bryniarski L, Kubinyi A, Ekiert-Kubinyi M, Kawecka-Jaszcz K. Postinfarction left ventricular pseudoaneurysm with left-to-right shunt: case report and review of the literature. International Journal of Cardiology 2010;139:199–201. [5] Van Tassel RA, Edwards JE. Rupture of heart complicating myocardial infarction. Analysis of 40 cases including nine examples of left ventricular false aneurysm. Chest 1972;61:104–16. [6] Moreno R, Gordillo E, Zamorano J, Almeria C, Garcia-Rubira JC, Fernandez-Ortiz A, Macaya C. Long term outcome of patients with postinfarction left ventricular pseudoaneurysm. Heart 2003;89:1144–6. [7] Eren E, Bozbuga N, Toker ME, Keles C, Rabus MB, et al. Surgical treatment of post-infarction left ventricular pseudoaneurysm: a twodecade experience. Texas Heart Institute Journal 2007;34:47–51. [8] Chen X, Qiu ZB, Xu M, Liu LL, Jiang YS, et al. Surgery for left ventricular aneurysm after myocardial infarction: techniques selection and results assessment. Chinese Medical Journal 2012;125:4373–9. [9] Frances C, Romero A, Grady D. Left ventricular pseudoaneurysm. Journal of the American College of Cardiology 1998;32:557–61. [10] Komeda M, David TE, Malik A, Ivanov J, Sun Z. Operative risks and long-term results of operation for left ventricular aneurysm. Ann Thoracic Surg 1992;53:22–9. [11] Pretre R, Linka A, Jenni R, Turina MI. Surgical treatment of acquired left ventricular pseudoaneurysms. Ann Thorac Surg 2000;70:553–7. [12] Stahle E, Bergstrom R, Nystrom S, Edlund B, Sjorgren I, Holmberg L. Surgical treatment of left ventricular aneurysm – assessment of risk factors for early and late mortality. European Journal of Cardiothoracic Surgery 1994;8:67–73.
Please cite this article in press as: Villanueva C, et al. Ruptured Left Ventricular False Aneurysm following Acute Myocardial Infarction: Case Report and Review of the Literature. Heart, Lung and Circulation (2014), http://dx.doi.org/10.1016/j. hlc.2014.07.069
