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J Thorac Cardiovasc Surg 2004;128:765-767
© 2004 The American Association for Thoracic Surgery
Brief communication |
a Department of Cardiac Surgery, Dedinje Cardiovascular Institute, Belgrade, Serbia and Montenegro, Yugoslavia
Received for publication March 8, 2004; revisions received March 29, 2004; accepted for publication April 6, 2004.
* Address for reprints: Predrag Milojevic, MD, FETCS, Department of Cardiac Surgery II, Dedinje Cardiovascular Institute, M. Tepica 1, 11040 Belgrade, Serbia and Montenegro, Yugoslavia
pmilojevic{at}sezampro.yu
Left ventricular pseudoaneurysm is an uncommon complication of transmural myocardial infarction. It usually forms several weeks after the infarction on the inferior or posterolateral left ventricular wall when cardiac rupture is contained by the adherent pericardium.
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We present a case of double inferoposterior left ventricular pseudoaneurysm. To our knowledge, this is the first reported case of double pseudoaneurysm successfully surgically repaired.
Clinical summary
A 45-year-old obese woman was transferred to our institution on an emergency basis with signs of imminent pericardial tamponade. Three months previously, she had acute transmural inferoposterior myocardial infarction that was treated conservatively. At the time of the initial event and 1 month after, routine transthoracic echocardiography demonstrated akinesis of the inferoposterior wall, with an estimated ejection fraction of 45% and no other abnormalities. Because of recurrent chest pain and dyspnea with persisting inferior ST-segment elevation on electrocardiography, the patient underwent treadmill stress testing 2 times, and the results of both tests were negative.
On the day of admission to our institution, chest radiography showed an enlarged heart with a localized bulge on the right contour of the cardiac silhouette. Transthoracic and transesophageal echocardiography demonstrated a 15-mm circular pericardial effusion, compression of the right atrium, and the presence of 2 separate pseudoaneurysms that communicated with the left ventricular cavity. The larger one was located on the inferoposterior left ventricular wall below the posteromedial papillary muscle and was 67 x 35 mm in diameter, with a 13-mm myocardial defect. The smaller one was located between the 2 heads of the papillary muscle and was 29 x 28 mm in diameter, with a 7-mm defect (Figure 1). Also, trivial mitral valve regurgitation was detected. Subsequent coronary angiography revealed proximal right coronary artery occlusion.
Emergency cardiac surgery was performed. Cardiopulmonary bypass was instituted through femoral cannulation. The pericardial cavity was full of blood without detectable leakage from the pseudoaneurysms at the time. The larger pseudoaneurysm was incised first, and the ventricular defect was closed with a Dacron patch, whereas the smaller pseudoaneurysm was closed with direct sutures (Figure 2). Tissue glue was applied topically, and the pseudoaneurysmal walls were overspread. The mitral valve was not touched. Single-vein bypass was performed on the right coronary artery. The postoperative course was uneventful, and the patient was discharged on the ninth postoperative day.
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Left ventricular pseudoaneurysm is a serious complication of transmural myocardial infarction. Generally, it appears several weeks after myocardial infarction, and more then half are localized on the posterolateral wall. Anterior myocardial infarctions are often associated with true aneurysm formation or, rarely, with free wall rupture that results in hemopericardium, tamponade, and death. An inflammatory reaction of the posterior pericardium might result in pericardial adhesions and formation of a posterior left ventricular pseudoaneurysm.1-3 The pseudoaneurysmal sac communicates with the left ventricle through the defect on the myocardial wall. The diameter of the defect is less than half the maximum diameter of the pseudoaneurysm. The wall of the pseudoaneurysm contains pericardium and clot without normal myocardial tissue.3
Pseudoaneurysms are often asymptomatic, and diagnosis is accidental.1-3 Considering the risk of leaking or secondary rupture, surgical3,4 treatment is recommended, although the long-term outcome of untreated pseudoaneurysm has been reported.5 Echocardiography usually allows establishment of a definite diagnosis.2
In our patient, an extremely rare double postinfarction pseudoaneurysm was founded. To our knowledge, this is the first reported case of double pseudoaneurysm successfully surgically repaired.
Double posterior wall rupture and pseudoaneurysm formation probably occurred 2 or 3 months after infarction, and leaking from them caused worsening of the patient's clinical condition. Echocardiography was the key in establishing correct diagnosis and planning subsequent emergency surgical treatment. Preoperatively, only coronary angiography was performed. Contrast left ventriculography was not performed because echocardiography clearly demonstrated 2 separate sacs in communication with the left ventricle through 2 separate wall defects and no communication between them (Figure 1). A curiosity of this case was the 2 negative treadmill stress test results obtained in the postinfarction period. Correct diagnosis was made on time by using noninvasive diagnostic modalities, and emergency operation resulted in successful postoperative recovery.
References
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