A 79-year-old man was admitted for surgical repair of a left ventricular pseudoaneurysm. He had experienced cardiac tamponade secondary to a ruptured chronic type A aortic dissecting aneurysm 3 weeks earlier. At that time, he underwent patch repair of the chronic dissecting aneurysm, under deep hypothermic circulatory arrest, and left ventricular apical venting with an 18F catheter. The venting site was repaired by means of 3-0 polypropylene sutures with Teflon felt pledgets after discontinuation of cardiopulmonary bypass. Ecchymosis of the epicardium was found around the apex; however, hemostasis was achieved easily after manual compression. The patient's postoperative course was uneventful, and he was discharged from the hospital 7 days after the operation.
Two weeks after discharge, the patient returned for outpatient follow-up evaluation of the post-repair ascending aorta. Computed tomographic (CT) scanning of the chest revealed a 3- × 4-cm pseudoaneurysm over the apex of left ventricle (Fig. 1). Because of the risk of spontaneous rupture, the patient was admitted for elective surgical intervention.
Fig. 1 Computed tomographic scan of the chest shows a 3- × 4-cm pseudoaneurysm (star) around the apex of the left ventricle.
Reoperation was performed through a repeat sternotomy with femoro–femoral bypass. The pseudoaneurysm was entered despite ventricular fibrillation, due to the huge thrombotic ascending aortic aneurysm that precluded cross-clamping. The left ventricle was communicating with the pseudoaneurysm through a perforation that was about 7 mm in diameter (Fig. 2). The perforation coincided with the site of the 18F left ventricular venting catheter from the previous operation. The perforation was repaired with a 3-0 pledgetted polypropylene suture, and the pseudoaneurysm was closed by linear repair. The patient recovered well and was discharged 7 days postoperatively.
Fig. 2 Intraoperative photograph (surgeon's view) reveals the 7-mm-diameter perforation that coincided with the previous site of the left ventricular venting catheter. The surgical probe indicates the perforation, which was the point of communication with the pseudoaneurysm.
A = ascending aorta; P = pseudoaneurysm; star = pericardium
Comment
A pseudoaneurysm of the left ventricle is a myocardial rupture contained by pericardium and thrombus with no remnants of myocardial tissue. It is a rare complication of myocardial infarction, but it has been reported after chest trauma, cardiac surgery, and endocarditis. 1 Left ventricular apical venting is frequently used to provide a dry operative field during aortic valve surgery or to prevent ventricular distention during systemic cooling. 2 False aneurysm secondary to left ventricular apical venting is an infrequent but well-known sequela and has been reported in the medical literature. 1
Ecchymosis of the apex after repair of the venting site may be the cause of pseudoaneurysm formation. Although the use of catheter-venting may not be responsible for the subsequent formation of the false aneurysm, the technique used in the repair of the venting site, along with the exact site of the vent insertion, is important to prevent any leakage of blood that might create sequelae.
Long-term follow-up is necessary for all patients who have had an aortic dissection. Computed tomographic scanning should be performed at the time of patient dismissal from the hospital. This scan will serve as a baseline for subsequent examinations, which should take place every 3 months during the 1st postoperative year and every 6 months thereafter. 3 The CT scan is a useful, noninvasive diagnostic tool for left ventricular pseudoaneurysm. As soon as the pseudoaneurysm is diagnosed, it should be surgically repaired in order to avoid spontaneous rupture. 1
Footnotes
Address for reprints: Chiung-Lun Kao, MD, Div. of Thoracic and Cardiovascular Surgery, Chang Gung Memorial Hospital at Chiayi, 6, Sec. West, Chia Pu Rd., Putzu City, Chiayi Hsien, Taiwan 613, R.O.C.
E-mail: sa11421@adm.cgmh.org.tw
References
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