Surgical Repair of a Basal Left Ventricular Pseudoaneurysm

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Clinical Presentation and Preoperative Course 

A 32-year-old female with a medical history of polycystic ovary syndrome (PCOS), smoking, and a body mass index (BMI) of 32 presented with positional chest pain that had been present for three weeks. An electrocardiogram (ECG) revealed PTa depression and Spodick’s sign. Serum cardiac markers were elevated, with a troponin-T level of 65 ng/L and a C-reactive protein level of 198 mg/L. A computed tomography (CT) scan revealed pericardial fluid with a maximum thickness of 18 mm. The patient was initially treated with ibuprofen and colchicine for suspected pericarditis, resulting in asymptomatic recovery. One month later, a pseudoaneurysm of the left ventricle (LV) was discovered on a transthoracic echocardiogram. In retrospect, a small aneurysm had already been visible on a previous CT scan. Cardiac magnetic resonance imaging (MRI) revealed a pseudoaneurysm measuring 45 mm x 50 mm with a broad neck of 9.6 mm 

Operative Procedure 

A median sternotomy was performed, and the pericardium was opened. Multiple intrapericardial adhesions were found, particularly around the aneurysm. Arterial cannulation was performed in the ascending aorta, followed by venous cannulation using a two-stage cannula in the right atrial appendage. A gauze sling was placed around the inferior vena cava. The adhesions around the aneurysm were removed to facilitate proper access. A second sling was placed through the transverse sinus to help expose the aneurysm, and the midline of the aneurysm was marked. 

After cross-clamping the aorta, cold crystalloid cardioplegia was administered. The left ventricular aneurysm was opened with a scalpel, and a portion of the aneurysmal tissue was excised to gain access to the affected area. The aneurysm cavity was inspected to assess the lesion. A bovine pericardial patch was measured for proper fit and sutured in the neck of the aneurysm using a 4-0 polypropylene suture.  
The remaining aneurysmal sac was closed over the bovine pericardial patch using two felt strips with 1-0 nonabsorbable braided polyester horizontal mattress sutures. Subsequently, a running suture was placed through both felt strips. The aortic cross-clamp was released, and the heart was gradually reperfused, returning to sinus rhythm. The patient was successfully weaned off cardiopulmonary bypass, after which protamine was administered. Drains were placed, and after ensuring hemostasis, the sternum was closed, and the patient was transferred to the intensive care unit (ICU). 
 
Postoperative Course 

Postoperatively, the patient was extubated the same day. The patient was discharged from the ICU on postoperative day one and recovered well. A transthoracic echocardiogram on postoperative day three showed no complications. 

Discussion and Key Takeaways 

Left ventricular pseudoaneurysm can arise from a wide range of etiologies, including coronary artery disease and spontaneous coronary artery dissection (SCAD) (1, 2). This case highlights that pseudoaneurysm formation can occur even in the absence of significant coronary pathology, such as in cases associated with pericarditis or viral infections (3). This further underscores the necessity for vigilant monitoring and timely intervention to mitigate adverse outcomes. 

References

1. Rumbinaitė E, Venckus V, Mamedov A, et al. Anterior basal left ventricular pseudoaneurysm in a single vessel disease. Perfusion. 2024;39(4):849-853.
2. Gong FF, Vaitenas I, Malaisrie SC, Maganti K. Mechanical Complications of Acute Myocardial Infarction: A Review. JAMA Cardiol. 2021;6(3):341-349.
3. Chimenti C, Verardo R, Grande C, Francone M, Frustaci A. Infarct-like myocarditis with coronary vasculitis and aneurysm formation caused by Epstein-Barr virus infection. ESC Heart Fail. 2020;7(3):938-941.

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