Repair of Large Left Ventricular Pseudoaneurysm

A 53-year-old male non-smoker with a family history of ischemic heart disease presented six weeks after a myocardial infarction, exhibiting worsening shortness of breath. The patient was normally fit and well. A recent coronary angiogram revealed severe three-vessel disease. A transthoracic echocardiogram (TTE) showed a large left ventricle (LV) pseudoaneurysm, moderate mitral regurgitation, and poor left ventricular function (ejection fraction was 30%).

The patient underwent an emergency LV pseudoaneurysm repair and coronary artery bypass graft x 1 (vein to left anterior descending artery). The right femoral vessels were exposed and then cannulated. A median sternotomy was performed before cardiopulmonary bypass was carried out. The pericardium was opened and a large LV pseudoaneurysm was identified. The surrounding infarction area involved mainly the lateral LV wall and part of the RCA territory. The adhesions were dissected out, and cardiopulmonary bypass was instituted. The pseudoaneurysm, consisting of a thin fibrotic pericardial sac, was then opened. The LV rupture was noted. The mitral valve and the papillary muscles were intact. The LV rupture site was repaired with two-layer patches (Dacron and Bovine pericardial patch) in order to reinforce the repair. The LAD target was identified and grafted with a vein. There were no other graftable targets. After the repair, the transesophageal echocardiogram (TEE) showed a persistently poor LV systolic function. Although the patient required only minimum inotropic support to be weaned off bypass, it was decided to insert an intra-aortic balloon pump.

The patient had a long intensive care unit stay, mainly because of respiratory complications, but ultimately made a good recovery and was discharged six weeks post-operatively.

Tips:

• Given the rarity of LV pseudoaneurysms, there is no consensus on treatment. A multidisciplinary decision was made to operate, as this was a matter of emergency. The rational was that the patient had myocardial infarction six weeks prior to his presentation. During this period, it was assumed that the heart tissue had already undergone the necessary changes that would make it easier to implant a patch. Any further delay was deemed unnecessary, as it might result in further clinical deterioration and an even higher-risk intervention.
• The authors recommend implanting two patches to strengthen the repair, especially in large ruptures.
• The patient had moderate mitral regurgitation. This was thought to be functional, therefore, it was decided not to intervene with respect to the mitral valve. After coming off bypass, intra-operative TEE showed mild MR. Further post-operative TTEs also showed mild MR.
• Once the adhesions around the heart were dissected and the pseudoaneurysm assessed, cross-clamp was applied in order to reduce the ischemic time, especially in the context of severe coronary disease.
• Although the benefit is uncertain, the authors would recommend intra-aortic balloon pump insertion to improve hemodynamics. In this case, it was certainly beneficial in the post-operative period, and the patient required only small doses of inotropes.