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311Ann Thorac Cardiovasc Surg Vol. 7, No. 5 (2001)
Case
Report
Introduction
Left ventricular pseudoaneurysm (LVPA) forms when a
cardiac rupture is contained by adherent pericardium or
scar tissue.1) Most LVPAs occur following myocardial
infarction, cardiac surgery, trauma, infection, or inflam-
mation.1) We report a patient who developed LVPA after
sutureless repair2) of a subacute left ventricular free wall
rupture (LVFWR) complicating acute myocardial infarc-
tion (AMI).
Case
A 63-year-old woman came to our hospital in June 1998
with chest and back pain that had persisted for 24 hours.
She had a cerebral hemorrhage 6 years prior. Electrocar-
diogram revealed ST segment elevation in leads aVL, and
V1 to V6. She was treated medically without coronary
angiography (CAG) or coronary intervention for over 24
hours after the onset of AMI. She lost consciousness sud-
denly due to electromechanical dissociation on the sec-
ond hospital day, and echocardiogram revealed pericar-
dial effusion. After cardiopulmonary resuscitation and
pericardiocentesis, her blood pressure and level of
consiousness improved, and we performed emergency
surgery for subacute LVFWR.
First surgery
After median sternotomy, the pericardium was opened
and 140 ml of fresh blood and clot was removed. A 5×5
cm infarcted area was observed in the anterior free wall
of the left ventricle (LV). A 10-mm myocardial tear par-
allel to the diagonal branch was found in the infarcted
area, and oozing from the tear was seen. After the bleed-
ing was stopped by finger compression over the tear, a
sutureless repair2) was performed without cardiopulmo-
nary bypass. A large patch of autologous pericardium
(8×12 cm) for covering the entire infarcted area was fixed
to the surface of the heart with GRF glue.
The patient’s postoperative recovery was uneventful.
Postoperative CAG revealed total occulusion of the di-
Left Ventricular Pseudoaneurysm after Sutureless Repair
of Subacute Left Ventricular Free Wall Rupture:
A Case Report
Kiyoshi Iha, MD,1 Ryo Ikemura, MD,1 Nobuyoshi Higa, MD,2 Mitsuru Akasaki, MD,3
Yukio Kuniyoshi, MD,4 and Kageharu Koja, MD4
From the Departments of 1Cardiovascular Surgery, 2Cardiology,
Chubu Tokushukai Hospital, 3Department of Cardiovascular Sur-
gery, Nambu Tokushukai Hospital, and 4Second Department of
Surgery, Faculty of Medicine, University of the Ryukyus, Okinawa,
Japan
Received December 14, 2000; accepted for publication April 19,
2001.
Adress reprint requests to Kiyoshi Iha, MD: Department of Car-
diovascular Surgery, Chubu Tokushukai Hospital, 3-20-1 Teruya,
Okinawa 904-8585, Japan.
A 65-year-old woman presenting with a left ventricular pseudoaneurysm 27 months after
sutureless repair of a subacute left ventricular free wall rupture complicating acute myo-
cardial infarction is described. An autologous pericardial patch and gelatin resorcin form-
aldehyde (GRF) glue were used in the repair. A small pseudoaneurysm bulged out over the
true aneurysm of the left ventricle. We performed a Dor operation and concomitant bypass
grafting to the right coronary artery. Although sutureless repair is an effective procedure
for subacute left ventricular free wall rupture, left ventricular pseudoaneurysm in the late
postoperative period may be a rare problem after this repair. (Ann Thorac Cardiovasc Surg
2001; 7: 311–4)
Key words: left ventricular pseudoaneurysm, left ventricular true aneurysm, sutureless repair,
left ventricular free wall rupture, acute myocardial infarction
312
Iha et al.
Ann Thorac Cardiovasc Surg Vol. 7, No. 5 (2001)
agonal branch. The other coronary arteries were nearly
normal. Left ventriculogram (LVG) revealed an anterior
wall true aneurysm with a broad base.
The patient had regular 6-month follow-up transtho-
racic echocardiography examinations. The echocardio-
gram 18 months after surgery was normal. However, a
subepicardial aneurysm was noted on the 24-month
echocardiogram. LVG demonstrated a LVPA originating
from the true aneurysm (Fig. 1). CAG revealed 90%
stenosis of the distal right coronary artery (seg. 3). The
patient refused surgical treatment, but 3 months later, she
was readmitted and LVG demonstrated that the
pseudoaneurysm had grown in diameter from 7.5 to 15.0
mm (Fig. 2). The patient underwent a second surgery 27
months after the sutureless repair.
Second surgery
After a usual median sternotomy, moderate adhesion was
observed surrounding the heart. There was some loose
adhesion between the autologous pericardial patch and
the myocardium. The pseudoaneurysm was 18×20 mm.
After removal of the thrombus, the orifice of the
pseudoaneurysm (8×10 mm) was confirmed. A Dor op-
eration3) was performed with the aid of cardiopulmonary
bypass because the pseudoaneurysm was formed on the
true aneurysm of the left ventricle. Fibrous scar tissue
around the orifice was partially resected. An endoventri-
cular circular suture of 2-0 polypropylene was passed
through the fibrous tissue above the transitional zone
between the normal and scarred muscle. The artificial
neck was closed with a Dacron patch. After closure, the
excluded external tissue was folded to reinforce the su-
ture line. Coronary artery bypass grafting to the poste-
rior descending artery was performed with a saphenous
vein graft.
The patient’s postoperative course was uneventful.
Postoperative LVG showed a satisfactory result and an
ejection fraction that had improved from 62% to 69%
(Fig. 3). The bypass graft to the posterior descending
artery was patent. The patient was discharged on day 21
after this second surgery.
Pathology
Pathological examination showed no myocardial element
in the pseudoaneurysmal wall and a mixed thrombus in-
side the pseudoaneurysm.
Discussion
LVPA is a rare complication of myocardial infarction,
cardic surgery, trauma, infection, or inflammation.1) Post
surgical pseudoaneurysms can occur after replacement
of the mitral valve or can arise on a previous ventriculo-
tomy.5) LVPA requires early diagnosis and subsequent
surgical correction, because it tends to rupture even in
the chronic phase and regardless of size.4) However, pa-
tients are often asymptomatic and the LVPA is found in-
cidentally upon imaging study.1,6) A high clinical index
of suspicion is needed to avoid missing the diagnosis.1)
What distinguishes the pseudoaneurysm from the LV true
aneurysm is discontinuity of the myocardium around the
aneurysmal cavity.1,6) The presence of a neck smaller than
Fig. 1. Left ventriculogram in 30° right anterior oblique projec-
tion 24 months after the first operation demonstrating anterior
wall pseudoaneurysm (7.5 mm×7.5 mm diameter) (arrows) from
the true aneurysm.
Fig. 2. Left ventriculogram in 30° right anterior oblique projec-
tion 27 months after first operation revealed that the anterior
wall pseudoaneurysm diameter had grown from 7.5 to 15.0
mm (arrows).
313
Left Ventricular Pseudoaneurysm after Sutureless Repair of Subacute Left Ventricular Free Wall Rupture
Ann Thorac Cardiovasc Surg Vol. 7, No. 5 (2001)
the cavity is strongly suggestive of pseudoaneurysm, and
LVG is the best tool for establishing a diagnosis.1) CAG
is usually necessary before surgery to evaluate the need
for concomitant bypass grafting.1) Transthoracic echo-
cardiography is a reasonable first diagnostic tool,1) and
regular follow-up by this means was useful in our case.
There are a few reports of coincident pseudoaneurysm
and true aneurysm.1,7-9) Most investigators have supported
surgery as the appropriate treatment for LVPA because
untreated pseudoaneurysms have an approximately 30%
to 45% risk of rupture.1,4,10) However, regardless of treat-
ment, patients with LVPA have a high mortality rate, i.e.,
23% in those treated surgically and 48% in those treated
medically.1) The mortality rate is significantly high dur-
ing the acute phase of MI and during redo operations.4)
Pretre et al.4) reported that because asymptomatic small
pseudoaneurysms (<3 cm diameter) have a relatively
stable course, regular echocardiography or magnetic
resonance imaging could be a reasonable approach in
patients who do not require myocardial revasculari-
zation or mitral valve surgery. Any increase in size
should point toward surgical treatment. The pseudo-
aneurysm in our patient grew from 7.5 mm to 15.0
mm in only 3 months. Usually, emergency repair of
the postsurgical pseudoaneurysm is technically diffi-
cult because of tight adhesion. We recommend prompt
surgical correction even for the asymptomatic small
pseudoaneurysm.
LVFWR is a catastrophic complication after AMI.
Sutureless repair is a relatively new procedure for sub-
acute LVFWR, reported by Pado in 1993.2) This proce-
dure facilitates hemostasis, and reduces the operation
time, and is associated with a decreased incidence of low
output syndrome.2) There have been many recent reports
of sutureless repair of subacute LVFWR.
Noda and associates11) reported that GRF glue ensures
tight adhesion between the patch and the myocardium
and that neither abnormal inflammatory cells nor giant
cells were found histologically in their case. In our case,
however, there was insufficient adhesion between the
autologous pericardial patch and the myocardium, even
in the late period. There has been a report of LVPA after
sutureless repair with fibrin glue.12)
With the sutureless repair there is the risk of re-rup-
ture or formation of a LV true aneurysm in the postop-
erative period.13) Close follow-up should be carried out
after sutureless repair of subacute LVFWR due also to
the possibility of pseudoaneurysm.
Conclusion
A 65-year-old woman presenting with left ventricular
pseudoaneurysm 27 months after sutureless repair of
subacute left ventricular free wall rupture complicating
acute myocardial infarction is described. Although
sutureless repair is an effective procedure for subacute
left ventricular free wall rupture, left ventricular pseudo-
aneurysm in the late postoperative period may be a rare
problem after this repair.
ab
Fig. 3. Postoperative left ventriculogram in 30° right anterior oblique projection following Dor operation demonstrating an improve-
ment in ejection fraction from 62 to 69%.
a: Diastolic phase. b: Systolic phase.
314
Iha et al.
Ann Thorac Cardiovasc Surg Vol. 7, No. 5 (2001)
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