Surgical Repair of Postinfarction Left Ventricular Pseudoaneurysm

Abstract

Left ventricular pseudoaneurysm is a serious and rare disorder that usually develops after acute myocardial infarction. It can lead to potentially lethal mechanical complications, such as acute left ventricular free wall rupture. This report presents the case of a 64-year-old man with a left ventricular pseudoaneurysm and myocardial rupture that was managed by left ventricular restoration with aneurysmectomy and coronary artery bypass with 2 grafts.

Keywords: Aneurysm, false; coronary artery bypass; myocardial infarction.

Fig. 1

A) Transthoracic echocardiogram shows a small, narrow neck defect connected to the ventricle. B) Coronary angiogram shows multivessel coronary artery disease. C) Cardiac magnetic resonance image shows inferolateral wall infarct with free wall rupture into a huge pseudoaneurysm sac that contains a large thrombus.

Fig. 2

The pseudoaneurysm is firmly adhered to the pericardium and the visceral pleura, and adhesiolysis is not possible. Therefore, cardiopulmonary bypass is initiated, after which the pseudoaneurysm site is accessed through left ventricular ventriculotomy with open left pleura. The supplemental video also shows portions of the cardiopulmonary bypass circuit. Supplemental motion image available for Figure 2.

Fig. 3

A) The size of the pseudoaneurysm is approximately 9 × 8 × 7 cm. Ventriculotomy and patch closure with bovine pericardium are performed. The supplemental video also shows the process of extracting the thrombus and organized hematoma and repairing the aneurysmal defect. B) Illustration of the procedure. The aneurysmal defect is repaired with a bovine pericardial patch. The procedure was performed as deeply as possible until healthy endocardial tissue was secured. Supplemental motion image available for Figure 3A.

Fig. 4

A) The ventriculotomy is repaired with Teflon felt mattress suture and running suture reinforced by surgical glue. B) Illustration of the procedure. The left ventricle is repaired with Teflon felt strips. Supplemental motion image available for Figure 4A.

Fig. 5

Concomitant coronary artery revascularization is performed. The left internal thoracic artery is anastomosed to the left anterior descending coronary artery, and the great saphenous vein is anastomosed to the distal right coronary artery. Supplemental motion image available for Figure 5.