Left Ventricular Pseudoaneurysms Discovered Early After Acute Myocardial Infarction: The Surgical Timing Dilemma

Abstract

Left ventricular pseudoaneurysm is a rare disease; it is defined as a ventricular rupture contained by epicardium, pericardial adhesions, or both. It most frequently occurs as a complication of acute myocardial infarction. Surgical treatment is recommended for pseudoaneurysms that are large or symptomatic and for those discovered less than 3 months after myocardial infarction. We report our experience with 2 patients who had left ventricular pseudoaneurysms discovered less than a week after inferior myocardial infarction. Both patients were middle-aged men with right coronary occlusion in whom the diagnoses were established by echocardiography during the first week after infarction. Because both patients were clinically stable, we opted to defer surgery until scarring could facilitate correction; this decision was based on a review of the literature showing that in-hospital mortality is higher with early surgery. The patients were monitored closely in the intensive care unit and were prescribed β-blockers and vasodilators. Both patients underwent left ventricular patch reconstruction with exclusion of the pseudoaneurysm and posterior septum; both received moderate inotropic support and prophylactic intra-aortic balloon pump assistance. Their postoperative courses were uneventful. In 5 prior reports describing 45 patients (13 with acute pseudoaneurysm [≤2 wk after infarction] and 32 with nonacute pseudoaneurysm), in-hospital mortality was 61.5% for patients in the acute group and 15.6% for the nonacute group (P = .0066). We recommend that clinicians consider deferring surgery for patients with stable acute left ventricular pseudoaneurysm to reduce the risks associated with early repair.

Keywords: Cardiac surgical procedures; complications; false aneurysm; heart surgery; heart ventricles; left ventricular dysfunction; male; middle-aged; myocardial infarction; surgery.

Fig. 1

Patient 1. Intraoperative photographs show A) the posterior left ventricular pseudoaneurysm after pericardiolysis, and B) left ventricular reconstruction with a Dacron patch.

Fig. 2

Patient 2. Intraoperative photographs show A) the posteroinferior left ventricular pseudoaneurysm contained only by transparent, thin epicardium, with no adhesions, and B) left ventricular reconstruction with a pericardial patch.