Causes of left ventricular pseudoaneurysms are heterogeneous and usually follow an acute infarction1 or a traumatic event.2 The development of left ventricular pseudoaneurysm after left ventricular remodeling is quite unusual.3,4 The approach to the left ventricular wall through a left posterolateral thoracotomy is a well-known surgical procedure in cardiac surgery.5,6 Shapira et al6 reported a case of redo surgery for left ventricular aneurysm through a left thoracotomy in a patient with patent coronary grafts. The first authors who reported repair of a left ventricular aneurysm through left thoracotomy were Bailey et al7 and Likoff and Bailey8 in the 1950s. Nowadays, most patients undergo surgery through a median sternotomy with the use of standard cardiopulmonary bypass and cardioplegic arrest.9,10 We report the experience of a surgical repair of a left ventricular pseudoaneurysm after ventricular remodeling through a left thoracotomy with the Port Access platform (Edwards Lifesciences, Irvine, CA USA).
We describe the case of a 66-year-old man who was operated on in March 2011 for left ventricular restoration and coronary artery bypass grafting (left internal mammary artery–diagonal; saphenous vein for obtuse marginal and posterior descending artery). He was admitted to the hospital for large anterior acute myocardial infarction: coronary angiography revealed the occlusion of the anterior descending artery and a three-vessel disease associated with a left ventricular aneurysm with very low ejection fraction (30%). Angio-NMR (Nuclear Magnetic Resonance) confirmed the left ventricular aneurysm, and the patient underwent coronary artery bypass grafting and left ventricular restoration on the 14th day after acute myocardial infarction. The left ventricular remodeling was carried out by a 3 × 6-cm Dacron Sauvage patch (GORE-TEX Cardiovascular Patch, W. L. Gore & Associates, Flagstaff, AZ USA), sutured by four 4/0 polypropylene sutures. The cavity thus excluded from the left ventricle was then closed by two Teflon (PTFE [polytetrafluoroethylene], Santec Medicalprodukte, Grosswallstadt, Germany) strips sutured by five U stitches of a polypropylene 0 (Polypropylene Ethicon Endo-Surgery, Norderstedt, Germany). The postoperative course was uneventful, and the patient was discharged on the seventh postoperative day under anticoagulation therapy to prevent embolism. The patient was asymptomatic for approximately 1½ years; thus, he experienced ongoing effort dyspnea. The echocardiography revealed a cavity near the apex of the left ventricle and the suspect of detachment of the intraventricular patch. There is flow from the left ventricle to the mass although no signs of pericardial effusion were found (see Video, Supplemental Digital Object 1, http://links.lww.com/INNOV/A37). Thus, the patient was transferred to the emergency department and underwent angio-RMN, revealing a large pseudoaneurysm of the left ventricle caused by the detachment of the Dacron Sauvage patch (Fig. 1). The patient was emergently operated on to treat the large pseudoaneurysm. Under selective right lung ventilation and after cardiopulmonary bypass institution through the right femoral vessels [under transesophageal echocardiography, the right femoral vein (24F) and the right jugular vein (17F) were cannulated; the right femoral artery was cannulated by a 23F cannula], a large anterior left thoracotomy (approximately 10 cm in length to obtain a complete control of the heart) via the fifth intercostal space was performed. The fifth intercostal space was chosen because of the presence of the pulse of the mass and after a careful evaluation of the angio-RMN revealing the fifth intercostal space as the best approach to treat the pseudoaneurysm. In fact, the pseudoaneurysm was just under the intercostal muscle, and it was opened during dissecting (Fig. 2): no rib was removed because the orifice of the pseudoaneurysm and the apex of the heart were under direct vision. It was a very large pseudoaneurysm arising from the detachment of the patch caused by the fragility of the infarcted tissues. Figure 2 shows clearly the orifice of the pseudoaneurysm due to the laceration of the myocardium just abreast the two strips of Teflon used to close the cavity excluded from the left ventricle. Under transesophageal echocardiography, the endoaortic clamp (Heart Port platform) was positioned near the sinotubular junction and the balloon was inflated; thus, blood cardioplegia was administered and the heart was then protected. The laceration was sutured by Prolene 0 stitches and Teflon patches. BioGlue (CryoLife’s BioGlue, Kennesaw, GA USA)was applied along the sutures. A second Dacron patch was sutured on the border of the pseudoaneurysm by a 4/0 polypropylene suture and the cavity was filled with BioGlue to protect the tissues that were located just under the rib. After deflating the endoaortic balloon, sinus rhythm was restored, and no signs of bleeding were detected. Cardiopulmonary bypass was weaned by using inotropes (dobutamine and adrenaline).
The postoperative course was uneventful although the patient required prolonged mechanical ventilation up to the sixth postoperative day (in the second postoperative day, the patient was unsuccessfully extubated). The patient was discharged on the 16th postoperative day, and angio-CT (computed-tomography) scanning did not show signs of bleeding from the left ventricle (Fig. 3).
This is a very rare case of left ventricular pseudoaneurysms arising from a detached intraventricular patch in patients previously operated on for ventricular remodeling. Causes of detachment were not completely clear but probably related to the fragility of the infarcted tissues. In fact, as Figure 2 shows, there was a laceration (approximately 1 cm) of the myocardium where the patch was sutured, and this was the orifice of the pseudoaneurysm.
Our experience confirms that left ventricular pseudoaneurysm is a life-threatening complication after left ventricular remodeling, and left thoracotomy via the fifth or the sixth intercostal space is feasible. Moreover, the possibility of avoiding an extensive tissue dissection should be considered, and the use of the endoaortic clamp may be useful to obtain this aim.
The advantages of the reparation of the pseudoaneurysm under aortic clamping are mainly related to the possibility of an accurate inspection of the tissues. On the contrary, on the beating heart, the bleeding may be high, and the risk for an inaccurate inspection or a sudden injury should be considered.
In conclusion, left thoracotomy is feasible in case of left ventricular pseudoaneurysm, and the endoaortic clamp allows reducing the tissue dissection; however, the endoclamp should be avoided in case of extensive peripheral vascular disease or for femoral arteries less than 7 mm in diameter,11 whereas there are no specific contraindications for left thoracotomy.
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Keywords:©2014 by the International Society for Minimally Invasive Cardiothoracic Surgery
Left ventricular pseudoaneurysm; Left thoracotomy; Minimally invasive surgery