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Surgical treatment of a giant left ventricular aneurysm - A case report

Gustavo Alves SchaitzaI; José Rocha Faria NetoII; Julio Cesar FranciscoVI; Cristiana Pellegrino BaenaII; Helcio GiffhornIII; Bruna OlandoskiIV; Leanderson Franco de MeiraVII; Luiz César Guarita-SouzaV

DOI: 10.5935/1678-9741.20140107

ABBREVIATIONS AND ACRONYMS

CPB: Cardiopulmonary bypass

MRI: Magnetic resonance imaging

NYHA: New York Heart Association

TEE: Transesophageal echocardiography

INTRODUCTION

Although a left ventricular aneurysm is a common complication following a myocardial infarction, its incidence has declined, primarily due to the treatment of a myocardial infarction with coronary angioplasty performed in the acute phase of the event. The condition can be classified as a true aneurysm when the aneurysm forms at the damaged wall of the myocardium and as a pseudoaneurysm when the cardiac rupture is contained by adherent pericardium or scar tissue[1,2].

The main complications of a left ventricular aneurysm are heart failure, ventricular arrhythmias, systemic embolization, cerebrovascular accident, and ventricular rupture. The main surgical indications occurring in patients with a true aneurysm, intractable ventricular arrhythmias and heart failure unresponsive to drug treatment. Other possible indications include refractory angina and systemic embolization in patients who cannot take oral anticoagulants. In cases of pseudoaneurysm, surgical treatment is the best option, given its high probability of symptom dissolution[2,3].

Surgical techniques currently in use for correction of a left ventricular aneurysm are based on reconstruction of the left ventricle or a reduction of its volume with the goal of restoring normal cardiac geometry[4,5].

The present article reports a case of a giant ventricular aneurysm post-myocardial infarction in a 59 year-old male patient and shows an example of a positive outcome of surgical correction with the ventricular remodeling technique. The case report contains full imaging documentation with cardiac magnetic resonance imaging and transesophageal echocardiography images.

 

CASE REPORT

A 59 year-old male patient suffered from hypertension and dyslipidemia. He was a smoker and had a positive family history for coronary artery disease. Following an acute myocardial infarction in February 2013, he underwent a circumflex coronary stent implantation. Twenty-five days after stent implantation, the patient presented with acute coronary symptoms, which were found to be due to stent occlusion; however, another angioplasty proved to be impossible due to technical difficulties.

In August 2013, the patient suffered heart failure, functional class III (NYHA). A giant aneurysm of the left ventricle was present. Transesophageal echocardiography (TEE) and cardiac magnetic resonance imaging (MRI) were performed (ejection fraction: 19% [Simpson]; left-end diastolic volume: 402.7 cm3; left-end systolic volume: 324 cm3; ejection fraction: 19%; left-end diastolic volume: 490 ml; left-end systolic volume: 398 ml). Left ventricle weight was 144 gm2. The aneurysm was 7.3 x 6.4 x 7.5 cm with tapered walls towards the base of the left ventricle; a thrombus was present (Figures 1A and 1B).

 


 

The patient underwent repair surgery of the left ventricle with geometric correction through a median sternotomy (video 1). Cardiopulmonary bypass (CPB) from the aorta to the right atrium was established under normothermia (Figure 2A). Myocardial protection was held with anterograde and retrograde cardioplegia under continuous normothermic esmolol, potassium, and magnesium.

 

 

After incising the aneurysm (video 2) and extracting a large thrombus (video 3) measuring 8 x 3 cm (Figure 2B), a 7 x 5 cm bovine pericardial patch was placed and anchored with Teflon wires (videos 4 and 5). A transition zone was established between the healthy myocardium and an area of fibrosis (video 6) using 2.0 ethibond thereby excluding the infarcted region and a geometric correction was performed (Figure 2C). The mitral valve was competent. Cardiopulmonary bypass time was 56 minutes and the aorta was clamped for 48 minutes. The patient was weaned from the CPB with a low dose of intravenous dobutamine, which was maintained until closure of the incision.

A new transesophageal echocardiography was performed and revealed a 30% (Simpson) ejection fraction; left-end diastolic volume of 138.6 cm3, and left-end systolic volume of 96.87 cm3 (Figure 3A).

 


 

The patient was extubated in the operating room and transferred to the intensive care unit where he remained for 36 hours. Intraoperative blood loss was 450 ml. He was discharged 72 hours later with prescriptions for carvedilol 12.5 mg daily and acetylsalicylic acid 100 mg daily. At the one month follow-up examination, the patient was at functional class I (NYHA). He underwent an MRI that identified: ejection fraction of 41%, left-end diastolic volume of 198 ml, left ventricular systolic volume of 115 ml, and left ventricular weight of 144 gm2 (Figure 3B).

 

DISCUSSION

Although left ventricular aneurysm is a common complication following myocardial infarction, its incidence has declined, primarily due to the treatment of myocardial infarction with coronary angioplasty performed in the acute phase of the event. The condition can be classified as a true aneurysm when the aneurysm forms at the damaged wall of the myocardium and as a pseudoaneurysm when the cardiac rupture is contained by adherent pericardium or scar tissue[1,2].

The main complications of a left ventricular aneurysm are heart failure, ventricular arrhythmias, systemic embolization, cerebrovascular accident, and ventricular rupture. The main surgical indications occur in patients with a true aneurysm; include intractable ventricular arrhythmias and heart failure not responsive to drug treatment. Other possible indications are refractory angina and systemic embolization in patients who cannot take oral anticoagulants. In cases of pseudoaneurysm, surgical treatment is the best option, given its high probability of symptom dissolution[2,3].

Surgical techniques currently in use for correction of a left ventricular aneurysm are based on reconstruction of the left ventricle or a reduction of its volume with the goal of restoring the normal cardiac geometry[4-6]. This case exemplifies a positive outcome of surgical correction with the ventricular remodeling technique. When appropriate indications are present, the procedure can result in improved ejection fraction of the left ventricle and ventricular volume reduction.

Video 1 - Giant left ventricular aneurysm before the establishment of the cardiopulmonary bypass. The aneurysm is clearly delimited by the surgeon fingers.

Video 2 - The aneurysm wall is opened revealing its extension.

Video 3 - A large thrombus measuring 8 x 3 cm is removed from the aneurysm wall.

Video 4 - After the thrombus removal, the bovine pericardial patch was placed and anchored with Teflon wires in order to reconstruct the geometry of the ventricular wall impaired by the aneurysm formation.

Video 5 - Bovine pericardial patch fully anchored to the wall.

Video 6 - A transition zone was established with 2.0 Ethibond between the healthy myocardium and an area of fibrosis, excluding the infarcted region.

REFERENCES

1. Vijayvergiya R, Pattam J, Rana SS, Singh JD, Puri GD, Singhal M. Giant left ventricular pseudoaneurysm presenting with hemoptysis. World J Cardiol. 2012;4(6):218-20. [MedLine]

2. Inan MB, Yazicioglu L, Acikgoz B, Tasoz R, Ozyurda, U. Giant posterolateral left ventricular aneurysm diagnosed 6 weeks after incomplete surgical revascularization. Ann Thoracic Surg. 2012;93(3):980-2.

3. Antman EM, Anbe DT, Armstrong PW, Bates ER, Green LA, Hand M, et al.; American College of Cardiology; American Heart Association Task Force on Practice Guidelines; Canadian Cardiovascular Society. ACC/AHA guidelines for the management of patients with ST-elevation myocardial infarction: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee to Revise the 1999 Guidelines for the Management of Patients with Acute Myocardial Infarction). Circulation. 2004;110(9):e82-292. [MedLine]

4. Jatene AD. Left ventricular aneurysmectomy: resection or reconstruction. J Thorac Cardiovasc Surg. 1985;89(3):321-31. [MedLine]

5. Dor V, Saab M, Coste P, Kornaszewska M, Montiglio F. Left ventricular aneurysm: a new surgical approach. Thorac Cardiovasc Surg. 1989;37(1):11-9. [MedLine]

6. Silveira Filho LM, Petrucci O, Vilarinho KA, Baker RS, Garcia F, Oliveira PP, et al. A bovine pericardium rigid prosthesis for left ventricle restoration: 12 years of follow-up. Rev Bras Cir Cardiovasc. 2011;26(2):164-72. [MedLine] View article

No financial support.

Authors' roles & responsibilities

GAS: Conception and study design, performing the procedures and/or experiments, writing of the manuscript or review of its content

JRFN: Conception and study design, performing the procedures and/or experiments

JCF: Drafting of the manuscript or review of its content

CPB: Drafting of the manuscript or review of its content

HG: Performing the procedures and/or experiments

BO: Performing the procedures and/or experiments

LFM: Final approval of the manuscript, performing the procedures and/or experiments

LCGS: Final approval of the manuscript, performing the procedures and/or experiments

Article receive on Wednesday, May 7, 2014

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