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An Echocardiographic Evaluation of Valvular Function and Ventricular Patch Repair During Surgical Exclusion of Left Ventricular Pseudoaneurysm

O'Donoghue, Rory D. MD*; Duncan, Andra E. MD*; Fraser, Thomas G. MD; Thomas, James D. MD

doi: 10.1213/ANE.0b013e3182291361
Cardiovascular Anesthesiology: Echo Rounds
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Published ahead of print August 4, 2011 Supplemental Digital Content is available in the text.

From the Departments of *Cardiothoracic Anesthesia, Infectious Disease, and Cardiovascular Medicine, Section of Imaging, Cleveland Clinic Foundation, Cleveland, OH.

Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal's Web site (www.anesthesia-analgesia.org).

Supported by NIH 1K23HL093065-01A2 (Dr. Duncan), Cleveland Clinic Department of Cardiothoracic Anesthesia.

The authors declare no conflicts of interest.

Reprints will not be available from the authors.

Address correspondence to Andra Duncan, MD, Department of Cardiothoracic Anesthesia, Cleveland Clinic, 9500 Euclid Ave./J-4, Cleveland, OH 44195. Address e-mail to duncana@ccf.org.

Accepted May 31, 2011

Published ahead of print August 4, 2011

A 23-year-old African male presented with recurrent fevers, chest pain, and hypotension to an outside institution. After a transthoracic echocardiogram revealed a left ventricular (LV) pseudoaneurysm, he was transferred to our institution for possible surgical intervention. The Cleveland Clinic IRB waived the requirement for patient consent for this report.

His clinical presentation and a subsequent coronary angiogram without evidence of coronary artery disease suggested a nonischemic, presumably infectious, etiology of the pseudoaneurysm. He was brought to the operating room for repair of the pseudoaneurysm, where a transesophageal echocardiogram (TEE) midesophageal (ME) 4-chamber view demonstrated moderate LV dysfunction with a pseudoaneurysm originating from the inferolateral wall below the mitral annulus (Fig. 1). Apical displacement of the point of mitral leaflet coaptation was noted. A modified transgastric short-axis view confirmed the defect in the inferolateral myocardial wall with continuous bidirectional flow on color flow Doppler (CFD) imaging. (see Supplemental Digital Content 1, Video 1, Loops 1 and 2, http://links.lww.com/AA/A303). A modified ME long-axis view demonstrated restricted systolic closing of the posterior mitral leaflet. ME 2-chamber view with CFD demonstrated a severe, posteriorly directed jet of mitral regurgitation (MR) (Supplemental Digital Content 1, Video 1, Loops 3 and 4, http://links.lww.com/AA/A303).

Figure 1

Figure 1

The surgical procedure included exclusion of the pseudoaneurysm with a 5-cm pericardial patch, mitral commissure plication, and annuloplasty ring placement. After cardiopulmonary bypass, TEE evaluation revealed a moderately echogenic, noncontractile patch in the mid- and basal inferolateral wall (Fig. 2). The ME 4-chamber view demonstrated severe LV dysfunction without an echo-free space lateral to the LV and absence of color Doppler flow, confirming exclusion of the pseudoaneurysm (Supplemental Digital Content 1, Video 1, Loop 5, http://links.lww.com/AA/A303). Adequate mitral valve repair without residual MR was confirmed with CFD. After a complicated postoperative course, he was discharged to a local hospital several weeks later.

Figure 2

Figure 2

Nine months later, he presented with recurrent fevers. Preoperative echocardiography documented LV patch dehiscence and mitral valve vegetations. He was brought to the operating room for patch repair and mitral debridement. Intraoperative TEE documented a large echo-free space lateral to the LV confirming reexpansion of the pseudoaneurysm. CFD revealed communication between the LV and pseudoaneurysm at the inferior border of the patch (Fig. 3). A large, mobile vegetation was observed on the posterior mitral leaflet (Supplemental Digital Content 2, Video 2, loops 1 and 2, http://links.lww.com/AA/A304). Surgical repair consisted of replacement of in situ pericardial patch, valve debridement, and a new annuloplasty ring. Post-bypass TEE documented successful pseudoaneurysm exclusion and mitral valve repair (Supplemental Digital Content 2, Video 2, Loop 3, http://links.lww.com/AA/A304). He was subsequently discharged to a long-term care facility.

Figure 3

Figure 3

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DISCUSSION

Two-dimensional echocardiography is the preferred diagnostic imaging modality for diagnosis of a ventricular pseudoaneurysm.1 It is also useful to assess the impact of the pseudoaneurysm on valvular function. A recent Echo Rounds described the distinction between a pseudoaneurysm and true aneurysm.2 Our report illustrates the impact of a pseudoaneurysm on the mitral valve resulting in severe MR and the evaluation of dehiscence of an exclusion patch.

Severe MR may occur as a direct result of an LV pseudoaneurysm and contribute to the complexity of the surgical repair. The echocardiographic approach to evaluation of MR in the presence of a pseudoaneurysm must include a comprehensive interrogation of the myocardial defect in relation to the mitral valve apparatus. The borders of the defect and their proximity to the papillary muscles and mitral annulus should be defined. Other causes of severe MR in a patient with an LV pseudoaneurysm must be eliminated (Table 1).

Table 1

Table 1

In this patient, severe MR occurred as a consequence of ventricular pathology. Similar to conditions such as “functional” MR, in which severe MR is a consequence of underlying ventricular disease despite normal mitral leaflets,3 the inferolateral myocardial wall defect, which bordered the posterior mitral annulus and papillary muscle insertion, distorted the geometry of the mitral apparatus. Mitral valve dysfunction consistent with a Carpentier type IIIb classification (restricted systolic motion of the posterior mitral valve leaflet relative to the annular plane) was documented.4,5 A severe, posteriorly directed MR jet was the result. Proper LV reconstruction with preservation of normal LV and mitral apparatus geometry corrected mitral valve function. The mitral annuloplasty ring effectively decreased the anteroposterior diameter of the annulus, improved leaflet apposition, and thus improved the MR.

A patch is usually required to surgically repair the defect and exclude the pseudoaneurysm. A double-patch technique may be used, with one patch applied inside and a second patch outside the ventricular wall.6 In-hospital mortality after repair ranges from 20% to 40%.1,7 Recurrence of the pseudoaneurysm occurs in 8% of patients within 2 years.1

TEE evaluation after bypass should assess the integrity of the ventricular patch for signs of dehiscence. The patch often appears as a nonmobile membrane with increased echogenicity, shadowing, or reverberations, separating the LV from the pseudoaneurysm. Spectral and color Doppler imaging may identify patch dehiscence via turbulent flow in the LV or pseudoaneurysm. Flow between the LV and pseudoaneurysm will be directed toward the pseudoaneurysm during systole with reversal during diastole. Flow is typically turbulent through a narrow orifice in a pseudoaneurysm because of high ventricular pressure. However, ambiguity may occur if a large communication is present with little pressure difference between the LV and pseudoaneurysm. Other imaging modalities, including pulsed and continuous wave Doppler, confirm timing and velocity of shunt flow. Three-dimensional imaging can further describe the size and location of the myocardial defect and visualize abnormal motion of the exclusion patch. Contrast injection may enhance visualization of patch dehiscence. If patch dehiscence presents acutely, cardiac tamponade may occur.

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DISCLOSURES

Name: Rory D. O'Donoghue, MD.

Contribution: Data analysis and manuscript preparation.

Name: Andra E. Duncan, MD.

Contribution: Data analysis and manuscript preparation.

Name: Thomas Fraser, MD.

Contribution: Data analysis and manuscript preparation.

Name: James Thomas, MD.

Contribution: Data analysis and manuscript preparation.

This manuscript was handled by: Martin J. London, MD.

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APPENDIX VIDEO LEGENDS

Video 1

Loop 1. Midesophageal 4-chamber view of inferolateral left ventricular pseudoaneurysm. Note significant apical displacement of point of mitral leaflet coaptation. LA = left atrium; LV = left ventricle; RV = right ventricle; **pseudoaneurysm.

Loop 2. Modified transgastric short-axis view at the level of mitral leaflet tips demonstrating continuous bidirectional flow by color flow Doppler through a large defect in the inferolateral wall. LV = left ventricle; **pseudoaneurysm.

Loop 3. Modified midesophageal long-axis view with 107-degree rotation demonstrating the pseudoaneurysm. Note significant tethering of mitral leaflets with restricted systolic closing of posterior mitral leaflet and incomplete leaflet coaptation (Carpentier type IIIb classification). LA = left atrium; LV = left ventricle; **pseudoaneurysm.

Loop 4. Midesophageal 2-chamber view with color Doppler of a severe, eccentric, posteriorly directed jet of mitral regurgitation demonstrating a large proximal flow convergence. LA = left atrium; LV = left ventricle.

Loop 5. Midesophageal 4-chamber view demonstrated a pericardial patch as a moderately echogenic and nonmobile membrane seen in the mid and basal segments of the inferolateral wall. The pseudoaneurysm cavity is decompressed and the echo-free space lateral to the LV is no longer visible because contents of this structure were emptied. LV = left ventricle; patch = ventricular exclusion patch; **remnant of pseudoaneurysm cavity.

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Video 2

Loop 1. Midesophageal 4-chamber view demonstrating moderately impaired left ventricular function with a large echo-free space lateral to the left ventricle (LV) documenting reexpansion of the pseudoaneurysm. Patch dehiscence is noted at the inferior border of the pericardial patch. Note the large vegetation attached to the anterior mitral valve leaflet. Defect = patch dehiscence; **pseudoaneurysm.

Loop 2. Live x-plane imaging of the interventricular septum with color flow Doppler demonstrating communication between the pseudoaneurysm and left ventricle (LV). The dotted line in the left-sided image denotes the orthogonal plane of the image on the right. Defect = patch dehiscence; **pseudoaneurysm.

Loop 3. Midesophageal 4-chamber view with color flow Doppler interrogation of the pericardial patch confirming adequate repair of pseudoaneurysm patch dehiscence. LA = left atrium; LV = left ventricle; **pseudoaneurysm.

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REFERENCES

1. Atik FA, Navia JL, Vega PR, Gonzalez-Stawinski GV, Alster JM, Gillinov AM, Svensson LG, Pettersson BG, Lytle BW, Blackstone EH. Surgical treatment of postinfarction left ventricular pseudoaneurysm. Ann Thorac Surg 2007;83:526–31
2. Gologorsky E, Gologorsky A, Barron ME, Hassan M, Ricci M, Salerno T. Echo rounds: transesophageal echocardiography images of an inferior wall pseudoaneurysm: a difficult differential diagnosis. Anesth Analg 2010;111:613–5
3. Mehra MR, Uber PA, Benitez RM. Cardiomyopathy and the dilemma of geometric mitral regurgitation. Curr Opin Cardiol 2009;24:179–83
4. Bonow RO, Carabello BA, Kanu C, de Leon AC Jr, Faxon DP, Freed MD, Gaasch WH, Lytle BW, Nishimura RA, O'Gara PT, O'Rourke RA, Otto CM, Shah PM, Shanewise JS, Smith SC Jr, Jacobs AK, Adams CD, Anderson JL, Antman EM, Fuster V, Halperin JL, Hiratzka LF, Hunt SA, Nishimura R, Page RL, Riegel B. ACC/AHA 2006 guidelines for the management of patients with valvular heart disease: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (writing committee to revise the 1998 Guidelines for the Management of Patients with Valvular Heart Disease): developed in collaboration with the Society of Cardiovascular Anesthesiologists: endorsed by the Society for Cardiovascular Angiography and Interventions and the Society of Thoracic Surgeons. Circulation 2006;114:e84–231
5. Carpentier A. Cardiac valve surgery: the “French correction.” J Thorac Cardiovasc Surg 1983;86:323–37
6. Yamamoto Y, Ushijima T, Takata M, Watanabe G. Double-patch sandwich repair for left ventricular free wall rupture. Interact Cardiovasc Thorac Surg 2011;12:872–4
7. Slater J, Brown RJ, Antonelli TA, Menon V, Boland J, Col J, Dzavik V, Greenberg M, Menegus M, Connery C, Hochman JS. Cardiogenic shock due to cardiac free-wall rupture or tamponade after acute myocardial infarction: a report from the SHOCK Trial Registry. J Am Coll Cardiol 2000;36:1117–22
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Clinician's Key Teaching Points By Roman M. Sniecinski M.D., Kent H. Rehfeldt M.D., Martin J. London M.D.
  • In contrast to a true left ventricular (LV) aneurysm, a pseudoaneurysm does not contain all layers of the ventricular wall and thus is more prone to expansion or rupture over time. Pseudoaneurysm formation, which may result from ischemia or less commonly infection, can significantly alter LV geometry, leading to inefficient contraction and distortion of the mitral valve apparatus causing functional mitral regurgitation (MR).
  • A pre- or intraoperative transesophageal echocardiogram can confirm the location and size of a pseudoaneurysm as well as define the mechanism and severity of any associated MR. Color flow and spectral Doppler imaging can demonstrate systolic flow of blood from the LV into the pseudoaneurysm cavity. Surgical repair with a pericardial patch may appear as a membrane with increased echogenicity causing shadowing or reverberation artifact; color flow Doppler interrogation should confirm that the pseudoaneurysm is no longer in communication with the LV cavity.
  • In this complex case, a large pseudoaneurysm altered the geometry of the LV and subvalvular mitral apparatus leading to significant functional MR necessitating both patch exclusion of the pseudoaneurysm and mitral valve repair. Months later, with associated mitral endocarditis, the patch dehisced. Color flow Doppler imaging demonstrated return of flow between the pseudoaneurysm and LV cavity necessitating additional surgical intervention.
  • It is important for the echocardiographer to be able to identify an LV pseudoaneurysm and characterize any contribution to MR that may be present. Functional MR, which results from alterations in LV geometry in the setting of normal mitral leaflets, may necessitate valve repair in addition to patch exclusion of the pseudoaneurysm.

Supplemental Digital Content

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© 2011 International Anesthesia Research Society