Surgical treatment of postinfarction left ventricular pseudoaneurysm

Ventricular Pseudoaneurysm and Free Wall Rupture After Acute Myocardial Infarction: JACC Focus Seminar 4/5

Postinfarction ventricular free-wall rupture is a rare mechanical complication, accounting for <0.01% to 0.02% of cases. As an often-catastrophic event, death typically ensues within minutes due to sudden massive hemopericardium resulting in cardiac tamponade. Early recognition is pivotal, and may allow for pericardial drainage and open surgical repair as the only emergent life-saving procedure. In cases of contained rupture with pseudo-aneurysm (PSA) formation, hospitalization with subsequent early surgical intervention is warranted. Not uncommonly, PSA may go unrecognized in asymptomatic patients and diagnosed late during subsequent cardiac imaging. In these patients, the unsettling risk of complete rupture demands early surgical repair. Novel developments, in the field of transcatheter-based therapies and multimodality imaging, have enabled percutaneous PSA repair as a feasible alternate strategy for patients at high or prohibitive surgical risk. Contemporary advancements in the diagnosis and treatment of postmyocardial infarction ventricular free-wall rupture and PSA are provided in this review.

Surgical techniques using an attached patch for large left ventricular pseudoaneurysm after inferior acute myocardial infarction

We report a case of large left ventricular pseudoaneurysm after inferior acute myocardial infarction. Patch repair is commonly performed; however, only a few studies have described specific surgical techniques for left ventricular pseudoaneurysm repair of the inferior left ventricular wall. As an optimal repair technique for left ventricular pseudoaneurysm of the inferior left ventricular wall is lacking, we believe our technique is safe and effective in repairing this pathology.

Echocardiography in the Recognition and Management of Mechanical Complications of Acute Myocardial Infarction

PURPOSE OF REVIEW

Although rare, the development of mechanical complications following an acute myocardial infarction is associated with a high morbidity and mortality. Here, we review the clinical features, diagnostic strategy, and treatment options for each of the mechanical complications, with a focus on the role of echocardiography.

RECENT FINDINGS

The growth of percutaneous structural interventions worldwide has given rise to new non-surgical options for management of mechanical complications. As such, select patients may benefit from a novel use of these established treatment methods. A thorough understanding of the two-dimensional, three-dimensional, color Doppler, and spectral Doppler findings for each mechanical complication is essential in recognizing major causes of hemodynamic decompensation after an acute myocardial infarction. Thereafter, echocardiography can aid in the selection and maintenance of mechanical circulatory support and potentially facilitate the use of a percutaneous intervention.

A Case of Left Ventricular Pseudoaneurysm as a Complication of Late-Presenting ST-Segment Elevation Myocardial Infarction

This case report delineates the clinical trajectory and management strategies of a 59-year-old Hispanic male diagnosed with a left ventricular pseudoaneurysm (LVPA) following a delayed presentation of ST-segment elevation myocardial infarction (STEMI), for which reperfusion treatment was not administered. Initially, an echocardiogram demonstrated an extensive anterolateral myocardial infarction, severe left ventricular systolic dysfunction, and an early-stage left ventricular apical aneurysm with thrombus, leading to the initiation of warfarin. Metabolic myocardial perfusion imaging via positron emission tomography indicated a substantial myocardial scar without viability, guiding the decision against revascularization. Post discharge, the patient, equipped with a wearable cardioverter defibrillator for sudden cardiac death prevention, experienced symptomatic ventricular tachycardia, which was resolved with defibrillator shocks. Subsequent imaging revealed an acute LVPA adjacent to the existing left ventricular aneurysm. Given the high surgical risk, conservative management was elected, resulting in thrombosis and closure of the pseudoaneurysm after two weeks. The patient eventually transitioned to home hospice, surviving an additional five months. This report underscores the complexities and therapeutic dilemmas in managing post-MI LVPA patients who are ineligible for surgical intervention.

Surgical treatment of a left ventricular pseudoaneurysm with an extracellular matrix patch

Left ventricle pseudoaneurysm is a rare and life-threatening complication of myocardial infarction that is formed as a result of left ventricle free wall rupture contained by the overlying pericardium. Urgent surgical repair is crucial, and in most reports, left ventricle was reconstructed with a Dacron or bovine pericardial patch. We present a case of a 66-year-old female with left ventricle pseudoaneurysm which was successfully repaired with an extracellular matrix patch.

Supplementary Information

The online version contains supplementary material available at 10.1007/s12055-023-01669-3.

Anterior basal left ventricular pseudoaneurysm in a single vessel disease

INTRODUCTION

Left ventricular pseudoaneurysm is a rare but serious clinicopathologic entity.

MATERIALS AND RESULTS

This article describes a case report of 51-year-old man who experienced recurrence of chest pain and dyspnea 4 months later after anterior ST elevation myocardial infarction of first diagonal branch. Anterior basal left ventricular pseudoaneurysm was diagnosed and successful surgical treatment was performed. One year after operation, patient has no cardiovascular events and remains in NYHA class II.

CONCLUSION

Cardiac magnetic resonance should be performed, if there is a suspicion of left ventricular pseudoaneurysm from transthoracic echocardiography. Surgery is the treatment of choice in case of left ventricular pseudoaneuryms because untreated lesions carry a significantly high risk of rupture.

Left Ventricular Pseudoaneurysm: A Rare but Fatal Complication of Myocardial Infarction

Left ventricular pseudoaneurysm is a ventricular free wall rupture contained within the adjacent adherent pericardium or scar tissue. Myocardial infarction (MI), cardiac surgery, and chest trauma are the common causes. The most common presenting symptoms of pseudoaneurysms are congestive heart failure, chest pain, and dyspnea, but a small percentage of patients may be asymptomatic. Early diagnosis and treatment are of prime importance because of the tendency of pseudoaneurysms to expand and rupture, with a high mortality rate, especially if left untreated. We present a case of a 65-year-old man who was found to have left ventricular pseudoaneurysm on a follow-up echocardiography within three weeks of an MI. He subsequently underwent patch repair and was discharged after medical optimization. Our case highlights the importance of maintaining a high clinical suspicion of pseudoaneurysm in a patient post-MI, as delayed diagnosis and treatment can be fatal.

Interventional management of mechanical complications in acute myocardial infarction

Mechanical complications following a myocardial infarction are uncommon, but with dramatic consequences and high mortality. The left ventricle is the most often affected cardiac chamber and complications can be classified according to the timing in early (from days to first weeks) or late complications (from weeks to years). Despite the decrease in the incidence of these complications thank to primary percutaneous coronary intervention programs -wherever this option is available-, the mortality is still significant and these infrequent complications are an emergent scenario and one of the most important causes of mortality at short term in patients with myocardial infarction. Mechanical circulatory support devices, especially if minimally invasive implantation is used avoiding thoracotomy, have improved the prognosis of these patients by providing stability until definitive treatment can be applied. On the other hand, the growing experience in transcatheter interventions for the treatment of ventricular septal rupture or acute mitral regurgitation has been associated to an improvement in their results, even though prospective clinical evidence is still missing.

Left ventricular pseudoaneurysmectomy in patient without hemodynamic instability: A case report

We present a case of a 66-year-old male with a history of two previous diagnoses of myocardial infarction, followed by drug-eluting stent implantation. During the check-up, he complained of dyspnea, fatigue, and dizziness. Echocardiography revealed a massive left ventricular pseudoaneurysm (LVP). According to the patient's clinical manifestations and radiologic data, urgent surgical intervention was performed. Postoperatively, several complications appeared, which were managed successfully. The patient was discharged in stable condition. This is an interesting case of massive LVP without hemodynamic instability.

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

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.

Case report: Spontaneous closure of ventricular pseudoaneurysm post-acute myocardial infarction with non-surgical therapy

Left ventricle (LV) pseudoaneurysm is a rare disorder post-acute myocardial infarction (AMI). Resection or closure of the pseudoaneurysm by surgery is recommended due to the high propensity of pseudoaneurysm rupture while surgery has also high risks. Conservative therapy could be acceptable in small pseudoaneurysms or patients with high surgical risks. Nevertheless, the risk evaluation and grasp of indication are not clear. This case reported an acute cyst-like LV pseudoaneurysm formation post-AMI-induced myocardial free wall rupture (MFWR), and the patient recovered with spontaneous closure of the fissure and shrinkage of the LV pseudoaneurysm through non-surgical therapy. Based on the observations in the echocardiogram, we proposed that intermittent closing of the fissure and interruption of the blood flow between the LV and the pseudoaneurysm due to LV contraction alleviated stress change on the pseudoaneurysm. The narrow fissure, small pseudoaneurysm, and intermittently interrupted blood flow that benefit fissure healing and pseudoaneurysm stabilization could indicate the prognosis of this patient. Drugs like β-blocker that decreased the stress on the pseudoaneurysm also led to the risk reduction of pseudoaneurysm rupture. To our knowledge, this is the first case that reports a spontaneous closure of LV pseudoaneurysm. The size of the fissure and the pseudoaneurysm, as well as the corresponding hemodynamic state, could be valuable to evaluate the risk and prognosis of the pseudoaneurysm. Optimized medical management was also helpful to pseudoaneurysm stabilization.

Left ventricular pseudoaneurysm repair utilizing P2 segment of mitral valve: a case report

Background

Left ventricular (LV) pseudoaneurysms are a rare occurrence typically seen after myocardial infarction (MI) or in patients with prior cardiac surgery and are associated with a significant risk of rupture and mortality. Management includes primary repair, epicardial patching, or percutaneous repair with occlusive devices.

Case presentation

This case report describes a 46-year-old male with a large LV pseudoaneurysm that was surgically patched with a segment of his mitral valve. To our knowledge, there has not been a documented repair utilizing a segment of the mitral valve.

Conclusions

The applicability of this technique is limited to cases with posteriorly located pseudoaneurysms near the mitral valve, thus allowing the P2 segment to be used as a patch. This is a novel approach to LV pseudoaneurysm repair, though careful consideration towards patient selection is warranted, as comorbid conditions may contribute to morbidity and mortality.

Surgical management for mechanical complications of acute myocardial infarction: a systematic review of long-term outcomes

BACKGROUND

Mechanical complications following acute myocardial infarction (AMI), though rare, are associated with significant morbidity and mortality. Surgical management remains a mainstay of therapy for these complications. The purpose of this review is to evaluate long-term outcomes data of surgical management for postinfarction free wall rupture, ventricular septal defect, papillary muscle rupture, and pseudoaneurysm.

METHODS

An electronic literature search was performed to identify original studies reporting long-term outcomes data of surgical management of one of the four mechanical complications following AMI. Studies were considered to have long-term outcomes if they at minimum included survival or mortality data up to one year.

RESULTS

A total of 285 studies were identified from the literature search. Of these, 29 studies with long-term survival data on surgically managed mechanical complications of AMI are included in the review. The majority of these are retrospective cohort studies or single-center case series. Five studies are included on free wall rupture, 18 on ventricular septal defect, 4 on papillary muscle rupture, and 2 on pseudoaneurysm. Detailed results are tabulated according to complication.

CONCLUSIONS

Long-term surgical outcomes of postinfarction mechanical complications remain understudied. Outcomes for ventricular septal defect repair are better represented in the literature than are outcomes for other mechanical complications, though available studies are still limited by small sample sizes and retrospective design. Further research is warranted, particularly for outcomes of acute pseudoaneurysm repair.

A Rare Case of Post-Mitral Valve Replacement Ventricular Pseudoaneurysm, Bioprosthetic Dehiscence, and Paravalvular Mitral Regurgitation

We present a rare case of a young patient who underwent a bioprosthetic mitral valve replacement and subsequently experienced a left ventricular pseudoaneurysm complicated by valve dehiscence and paravalvular mitral regurgitation, demonstrated by multimodality imaging and confirmed during surgical repair. (Level of Difficulty: Advanced.)

Minimally invasive bail-out transthoracic coiling of giant cardiac pseudoaneurysm with good long-term result

BACKGROUND

We report a case of successful minimally invasive transthoracic coiling of a left ventricle pseudoaneurysm after iatrogenic cardiac perforation with a good long-term result. The pseudoaneurysm could be repaired neither by an open surgery because of poor general state of the patient nor interventionally because of a partial sealing with an Amplatzer Septal Occluder blocking the tight neck of the aneurysm.

METHODS AND RESULTS

We performed a transthoracic coiling of the left ventricle pseudoaneurysm using a direct ultrasound-guided puncture via intercostal access below the lingula. The access puncture was performed during a single lung apnea at the end of an expiration phase with a contralateral single lung ventilation. The patient successfully recovered and has been followed-up during the 5 years.

CONCLUSIONS

Transthoracic coil embolization is a minimally invasive treatment option for otherwise inoperable patients with cardiac pseudoaneurysms with good long-term results.

A Rare Case of a Left Ventricular Pseudoaneurysm With Lateral Wall Rupture

In this report, we present a case of a 51-year-old male patient with a left ventricular (LV) pseudoaneurysm and a ruptured lateral wall due to a previous myocardial infarction. This patient was referred to the Coronary Care Unit with a past history of acute coronary syndrome of two months. He presented with palpitations and acute pulmonary edema upon admission. Color Doppler detected a ruptured lateral ventricular wall, and an echocardiogram confirmed the presence of a lateral ventricular wall pseudoaneurysm. Emergency LV aneurysmal rupture repair surgery was performed on this patient, and the postoperative findings were stable till discharge.

Surgical and Conservative Treatment of Post-infarction Left Ventricular Pseudoaneurysm

Background

Post-infarction left ventricular (LV) pseudoaneurysm is a rare mechanical complication of myocardial infarction that carries a substantial risk of sudden rupture. The purpose of this study was to compare the surgical results of post-infarction LV pseudoaneurysm with those of conservative treatment.

Methods

From 2016 to 2021, 22 patients were hospitalized for LV pseudoaneurysm, including 17 cases (77.3%) caused by myocardial infarction. Of the 17 patients, 10 (58.8%) underwent surgical repair, while seven (41.2%) were treated medically. The clinical course, echocardiograph data, and surgical outcomes were analyzed. Survival rates of the surgical and conservative groups were compared.

Results

There were no perioperative deaths. Intra-aortic balloon pumping support was required in two (20%) patients. No follow-up mortality was observed in the surgical group and at the last follow-up, all the patients were classified as New York Heart Association class I–II. In the conservative group, there was one (14.3%) hospital death and two (28.6%) additional deaths during follow-up. A significant difference was found in survival between the two groups (P = 0.024).

Conclusions

Surgical repair of post-infarction LV pseudoaneurysm can be performed with good results, while conservative treatment carries a significant risk of sudden death. Surgical repair is indicated for every patient diagnosed, even those with a small pseudoaneurysm without symptoms.

Percutaneous closure of left ventricular pseudoaneurysm using simultaneous transseptal and transapical approach: a case report

Background 

Left ventricular (LV) pseudoaneurysm (PSA), also referred to as contained LV wall rupture, is a clinically uncommon but potentially life-threatening condition that can occur after myocardial infarction or cardiac surgery. If the anatomic characteristics of LV PSA are not eligible for the transfemoral approach, percutaneous closure of LV PSA can be technically difficult and appropriate approach selection may contribute to procedural success.

Case summary 

An enlarging LV PSA was discovered in a 65-year-old man with Marfan syndrome and three prior cardiothoracic surgeries. Arterial access was not possible due to invagination of the previously placed surgical graft in the descending thoracic aorta. This was managed with a novel approach of simultaneous transseptal LV access and direct puncture of PSA through the chest wall followed by a vascular plug placement.

Discussion 

This case demonstrates that percutaneous LV PSA closure using a hybrid approach of transseptal and direct apical puncture is a feasible and effective alternative for high-risk surgical candidates, although the anatomic characteristics are unsuitable for the transfemoral approach.

Cardiac Outpouchings: Definitions, Differential Diagnosis, and Therapeutic Approach

Background and Aims

Cardiac outpouchings encounter a series of distinct congenital or acquired entities (i.e. aneurysms, pseudoaneurysms, diverticula, and herniations), whose knowledge is still poorly widespread in clinical practice. This review aims to provide a comprehensive overview focusing on definition, differential diagnosis, and prognostic outcomes of cardiac outpouchings, as well as further insights on therapeutic options, in order to assist physicians in the most appropriate decision-making.

Methods

The material reviewed was obtained by the following search engines: MEDLINE (PubMed), EMBASE, Google Scholar, and Clinical Trials databases, from January 1966 until March 2021. We searched for the following keywords (in title and/or abstract): (“cardiac” OR “heart”) AND (“outpouching” OR “outpouch” OR “aneurysm” OR “pseudoaneurysm” OR “false aneurysm” OR “diverticulum” OR “herniation”). Review articles, original articles, case series, and case reports with literature review were included in our search. Data from patients with congenital or acquired cardiac outpouchings, from prenatal to geriatric age range, were investigated.

Results

Out of the 378 papers initially retrieved, 165 duplicates and 84 records in languages other than English were removed. Among the 129 remaining articles, 76 were included in our research material, on the basis of the following inclusion criteria: (a) papers pertaining to the research topic; (b) peer-reviewed articles; (c) using standardized diagnostic criteria; and (d) reporting raw prevalence data. Location, morphologic features, wall motion abnormalities, and tissue characterization were found to have a significant impact in recognition and differential diagnosis of cardiac outpouchings as well as to play a significant role in defining their natural history and prognostic outcomes.

Conclusions

Careful recognition of cardiac outpouchings remains a diagnostic challenge in clinical practice. Due to a broad cluster of distinctive and heterogeneous entities, their knowledge and timely recognition play a pivotal role in order to provide the most appropriate clinical management and therapeutic approach.

3D Printing in Modern Cardiology

BACKGROUND

3D printing represents an emerging technology in the field of cardiovascular medicine. 3D printing can help to perform a better analysis of complex anatomies to optimize intervention planning.

METHODS

A systematic review was performed to illustrate the 3D printing technology and to describe the workflow to obtain 3D printed models from patient-specific images. Examples from our laboratory of the benefit of 3D printing in planning interventions were also reported.

RESULTS

3D printing technique is reliable when applied to high-quality 3D image data (CTA, CMR, 3D echography), but it still needs the involvement of expert operators for image segmentation and mesh refinement. 3D printed models could be useful in interventional planning, although prospective studies with comprehensive and clinically meaningful endpoints are required to demonstrate the clinical utility.

CONCLUSION

3D printing can be used to improve anatomy understanding and surgical planning.

Double heart - chronic large missed pseudoaneurysm of left ventricle

Myocardial infarction is considered the most common cause of left ventricular pseudoaneurysm. Large missed pseudoaneurysm of the left ventricle incidentally diagnosed and treated conservatively.

Mechanical Complications of Acute Myocardial Infarction: A Scientific Statement From the American Heart Association

Over the past few decades, advances in pharmacological, catheter-based, and surgical reperfusion have improved outcomes for patients with acute myocardial infarctions. However, patients with large infarcts or those who do not receive timely revascularization remain at risk for mechanical complications of acute myocardial infarction. The most commonly encountered mechanical complications are acute mitral regurgitation secondary to papillary muscle rupture, ventricular septal defect, pseudoaneurysm, and free wall rupture; each complication is associated with a significant risk of morbidity, mortality, and hospital resource utilization. The care for patients with mechanical complications is complex and requires a multidisciplinary collaboration for prompt recognition, diagnosis, hemodynamic stabilization, and decision support to assist patients and families in the selection of definitive therapies or palliation. However, because of the relatively small number of high-quality studies that exist to guide clinical practice, there is significant variability in care that mainly depends on local expertise and available resources.

Thrombosed left ventricular pseudoaneurysm following myocardial infarction: a case report

BACKGROUND

Pseudoaneurysm of inferior wall of the left ventricle is an uncommon complication of myocardial infarction with high mortality.

CASE PRESENTATION

We report the case of a 63-year-old Tunisian man, diagnosed with a thrombosed left ventricular pseudoaneurysm and a pericardial effusion after 1 week of angina.

CONCLUSIONS

Left ventricular pseudoaneurysm is a serious complication of myocardial infarction that has atypical presentations. Diagnosis is generally established by transthoracic echocardiography but confirmed by magnetic resonance imaging. Urgent surgery is the treatment choice given the risk of embolization and rupture.

Mechanical Complications of Acute Myocardial Infarction: A Review

Importance

Mechanical complications of acute myocardial infarction include left ventricular free-wall rupture, ventricular septal rupture, papillary muscle rupture, pseudoaneurysm, and true aneurysm. With the introduction of early reperfusion therapies, these complications now occur in fewer than 0.1% of patients following an acute myocardial infarction. However, mortality rates have not decreased in parallel, and mechanical complications remain an important determinant of outcomes after myocardial infarction. Early diagnosis and management are crucial to improving outcomes and require an understanding of the clinical findings that should raise suspicion of mechanical complications and the evolving surgical and percutaneous treatment options.

Observations

Mechanical complications most commonly occur within the first week after myocardial infarction. Cardiogenic shock or acute pulmonary edema are frequent presentations. Echocardiography is usually the first test used to identify the type, location, and hemodynamic consequences of the mechanical complication. Hemodynamic stabilization often requires a combination of medical therapy and mechanical circulatory support. Surgery is the definitive treatment, but the optimal timing remains unclear. Percutaneous therapies are emerging as an alternative treatment option for patients at prohibitive surgical risk.

Conclusions and Relevance

Mechanical complications present with acute and dramatic hemodynamic deterioration requiring rapid stabilization. Heart team involvement is required to determine appropriate management strategies for patients with mechanical complications after acute myocardial infarction.

Delayed presentation of acute coronary syndrome with mechanical complication during COVID-19 pandemic: a case report

Background

The World Health Organization declared coronavirus disease 2019 (COVID-19) a global pandemic on 11 March 2020. We report a patient with acute myocardial infarction (AMI) who presented late due to fears of contracting COVID-19.

Case summary

A 65-year-old man with a history of hypertension presented late to the emergency department (ED) with AMI. He gave a 2-month history of exertional angina but avoided seeking medical consult due to fears of contracting COVID-19. On the day of admission, he had 4 h of severe chest pain before presenting to the ED. He was hypotensive and tachycardic on arrival. Electrocardiogram showed inferolateral ST-elevation myocardial infarction. Chest radiograph revealed widened superior mediastinum and bedside echocardiogram revealed inferoseptal and inferolateral hypokinesia with features of cardiac tamponade. An urgent computed tomography aortogram showed possible left ventricular (LV) wall perforation with resulting haemopericardium and cardiac tamponade. Subsequent coronary angiogram showed 100% occlusion of mid left circumflex artery and a contained LV wall rupture was confirmed with LV ventriculogram. He was transferred to a tertiary centre and underwent successful emergency surgical repair.

Discussion

Our index case demonstrates the impact of the COVID-19 pandemic on health seeking behaviour due to fears of contracting COVID-19 and the ensuing impact of delayed medical intervention. Cardiologists worldwide are seeing an alarming rate of rare complications of AMI in patients who present late. Physicians need to be aware of this phenomenon and have an active role to play in public education.

Recurrent left ventricular pseudoaneurysm with an ominous presentation

We present a case of a 58-year-old male with a recurrent left ventricular pseudoaneurysm. Two years before, the patient underwent repair of an apical aneurysm with a thrombus, which was very likely infected and complicated by huge pseudoaneurysm. The dramatic presentation of the recurrent pseudoaneurysm, as it invaded the left chest wall tissue and protruded into the skin through an intercostal space, and the complexity of the procedures are well documented by surgical and accompanying technical images.

Double-patch and glue repair of a postinfarction left ventricular pseudoaneurysm

An 85-year-old man with appetite loss, lightheadedness, and leg edema was referred to our institution. Computed tomography and transthoracic echocardiography revealed a left ventricular pseudoaneurysm with a maximal diameter of 80 mm and severe mitral regurgitation. Coronary angiography showed 90% stenosis and total occlusion of the left circumflex artery at segments 11 and 12, respectively. He was diagnosed with postinfarction left ventricular pseudoaneurysm and underwent patch repair using two bovine pericardium patches and biological glue, mitral valve replacement, and coronary artery bypass grafting. His postoperative course was uneventful.

[Giant left ventricular false aneurysme revealing a silent myocardial infarction]

Left ventricular false aneurysms are rare. They are secondary to a myocardial rupture which is contained by adherent pericardium and scar tissue. LV pseudoaneurysm contains no endocardium or myocardium unlike left ventricular true aneurysm. Most cases of LV pseudoaneurysm are related to acute myocardial infarction in inferior or posterior wall. We report a case of a 56-year-old man with a medical history of chronic cigarette smoking, dyslipidemia, and obesity. The patient had no myocardial infarction before. He was admitted for evaluation of important shortness of breath at effort without chest pain for 5 months. Physical exam find an enlarged left ventricular. The electrocardiogram revealed Q waves and ST segment elevation in leads V1 to V6. Transthoracic echocardiogram showed a large thrombosed apical left ventricular false aneurysm, severe left ventricular dysfunction, which were confirmed by cardiac magnetic resonance imaging, this exam also showed no viability in the mid left anterior descending coronary artery territory. The coronary angiography showed an occlusion of the mid left anterior descending coronary artery and a stenosis of the first diagonal artery. The patient was offered a surgical aneurysectomy with coronary artery bypass. The surgery was successful with amelioration of symptoms. We present a rare case of a giant false left ventricular aneurysm complicating a silent myocardial infarction in the anterior wall. The diagnosis is made by cardiac echocardiogram and cardiac magnetic resonance imaging. Because of the important risk of rupture, the surgical treatment is required.

Acute respiratory distress secondary to a huge chronic left ventricular pseudo-aneurysm

Pseudo-aneurysms are a rare, potentially life-threatening complication of a myocardial infarction. We present the case of a 45-year-old male who was brought to the emergency department in extremis and had a previous history of a late presentation inferior ST-elevation myocardial infarction treated percutaneously. Clinical examination revealed evidence of cardiogenic shock, pulmonary edema and a pulsatile epigastric mass. Chest X-ray demonstrated marked cardiomegaly and pulmonary edema. Urgent echocardiography confirmed the presence of a huge basal inferior wall pseudo-aneurysm with bi-directional flow. This was also associated with severe mitral regurgitation, due to posterior mitral annular involvement. The patient was transferred to the local cardiothoracic surgical unit where he underwent emergency repair of the pseudo-aneurysm and mitral valve replacement. Despite the surgery being complex he made a full recovery.

Intraoperative real-time three-dimensional transesophageal echocardiography as a precise navigator for a successful complicated postoperative left ventricular pseudoaneurysm repair: a case report

Background

Left ventricular pseudoaneurysm (LV-PAN) formation is a rare complication after cardiac surgery and mainly occurs after mitral valve surgery. Echocardiography plays a critical role in the assessment of rupture location, orifice geometry, and anatomical relationship with surrounding structures.

Case presentation

A 56-year-old man presented with LV-PAN formation 1 year after aortic root replacement combined with aortic replacement despite the lack of direct manipulation of the rupture site in the procedure and postoperative myocardial infarction. Intraoperative real-time three-dimensional transesophageal echocardiography (RT 3-D TEE) during surgical repair of the LV-PAN facilitated understanding of the shape of the LV-PAN orifice and the exact anatomical relationship between the rupture site and the posteromedial papillary muscle. Information sharing with surgeons contributed to avoiding direct papillary muscle injury and thus mitral valve deformation.

Conclusion

LV-PAN formation after cardiac surgery can present without direct manipulation of the rupture site and major coronary lesion. Intraoperative RT 3-D TEE can facilitate better understanding of the anatomical relationship between the rupture site and the posteromedial papillary muscle and allow for information sharing to avoid complications during surgical repair.

Calcified Left Ventricular Pseudoaneurysm of the Base of the Heart

Cardiac pseudoaneurysms of noninfectious or nonischemic etiology are rare. This case report illustrates the surgical management of a patient with a large postsurgical calcified pseudoaneurysm located in the base of the heart that was disrupting the continuity between the aortic and mitral annulus.

Intraoperative diagnosis of an unsuspected ruptured left ventricular aneurysm using transesophageal echocardiography: A case report

Transesophageal echocardiography (TEE) enables a more accurate visualization of left ventricular posterior aneurysms than transthoracic echocardiography due to the close proximity of the esophagus to the posterior ventricular wall. Therefore, TEE is essential for the accurate diagnosis of posterior aneurysm, particularly in urgent settings where preoperative assessments may be insufficient.

Concurrent true inferoposterior left ventricular aneurysm and ventricular septal rupture secondary to inferior myocardial infarction: a case report

Background

Although left ventricular aneurysm (LVA) is the most common mechanical complication of myocardial infarction (MI), it rarely involves the inferior or posterior left ventricular wall. Ventricular septal rupture (VSR) may be a fatal mechanical complication of MI but rarely occurs in the posterior or inferior portion of the interventricular septum. Thus, LVA and VSR as two mechanical complications of MI in the same patient are extremely rare.

Case summary

A 65-year-old woman, who had inferior ST-segment elevation myocardial infarction 2 months before without reperfusion therapy, was admitted with exertional dyspnoea for 1 month. Echocardiography and computed tomography revealed true inferoposterior LVA and VSR as concurrent complications of MI. These imaging findings were confirmed during cardiac surgery. After successful coronary bypass grafting and ventriculoplasty, the patient recovered quickly and was discharged from the hospital.

Discussion

A rare case of post-infarction inferoposterior LVA with concurrent interventricular septal rupture was reported. Transthoracic and transoesophageal echocardiography and cardiac computed tomography were valuable tools for the diagnosis of this rare condition. Combined coronary bypass grafting and ventriculoplasty were effective in treating this often fatal complication of inferior MI.

Left ventricle pseudoaneurysm: Diagnosis by a new murmur

Incomplete rupture of the ventricle free wall can occur after myocardial infarction. This occurs when an organized thrombus and the pericardium seal the ventricular perforation. This can progress to the formation of a left ventricle pseudoaneurysm (LVPA). A 70-year-old male with an antero-septal ST-elevation myocardial infarction (STEMI) underwent an emergent left heart catheterization which revealed severe three-vessel disease with occluded grafts, non-amenable to re-vascularization, and an apical thrombus. As he was high-risk for repeat coronary artery bypass graft, he was medically managed. Transthoracic echocardiogram (TTE) showed a normal left ventricle ejection fraction (LVEF), apical anterior and inferior wall akinesis, moderate sized apical thrombus, and pericardial thickening. On hospital day 7, examination revealed a new 3/6 to-and-fro murmur that was loudest at the apex. The patient was asymptomatic with normal vital signs. A repeat TTE revealed an apical wall rupture with flow into the pericardial cavity and absence of the apical thrombus. A LVPA was diagnosed and the patient was immediately referred for surgical repair. This case illustrates the potential for developing LVPA in STEMI patients and the importance of physical examination. If identified early a potential emergent situation in a previously asymptomatic patient can be averted, thereby preventing fatal consequences. <Learning objective: With the growing use of diagnostic testing the importance of physical examination is being lost. However, with an astute cardiac examination, potential complications such as a left ventricular pseudoaneurysm can be identified and promptly managed. In addition, a ventricular pseudoaneurysm must be considered in the differential as a rare complication in post ST-elevation myocardial infarction patients with a new murmur.>.

Left Ventricular Pseudoaneurysm: An Overview of Diagnosis and Management

Left ventricular pseudoaneurysm is a rare but life-threatening disorder that is frequently reported secondary to myocardial infarction or cardiac surgery. In this article, we chronicle the case of a patient with no prior risk factors who presented with a 2-week history of nonexertional atypical left chest pain. Apical 2-chamber transthoracic echocardiography revealed an unexpected outpouching of basal inferoseptal wall of the left ventricle, which had a narrow neck and relatively wide apex. The patient was diagnosed with left ventricular pseudoaneurysm and medical therapy was initiated. He refused to undergo the surgical intervention and subsequently, he was discharged from the hospital in stable condition. This article illustrates that physicians should be vigilant for atypical presentations of left ventricular pseudoaneurysm, and a high index of suspicion should be maintained for this stealth killer while performing appropriate diagnostic imaging. Additionally, we review the currently available approaches to diagnosis and management in these patients.

Repair of Enlarging Left Ventricular Pseudoaneurysm Two Months After Coronary Artery Bypass Grafting

Enlarging left ventricular pseudoaneurysms are a rare complication (especially after surgical revascularization) and require tailored surgical decision making and techniques for repair. We present a challenging patient with a rapidly enlarging left ventricular pseudoaneurysm 4 weeks after coronary bypass. The repair was approached through a left thoracotomy using circulatory arrest with selective antegrade cerebral perfusion.

Off-pump sutureless repair for ischemic left ventricular free wall rupture: a systematic review

Background

Clinical results of ischemic left ventricular free-wall rupture show high mortality rates.

Methods

We reviewed studies published after 1993 on PubMed.

Results

A sutureless technique using fibrin glue sheets or patches with/without fibrin glue might contribute to improved clinical results. However, some technique limitations remain for blowout-type ruptures, and the possibility of a pseudoaneurysm formation at the repair site after surgery should be considered.

Conclusions

The sutureless technique can be a promising strategy for the treatment of ischemic rupture, but serial echocardiographic studies should be mandatory for diagnosing a left ventricular pseudoaneurysm formation thereafter.

Surgical treatment of post-infarction left ventricular pseudoaneurysm: Case series highlighting various surgical strategies

Introduction and objective

The left ventricular pseudoaneurysm (LVP) is rare, the surgical experience is limited and its surgical treatment remains still a challenge with an elevated mortality. Herein, it is presented a retrospective analysis of our experience with acquired post infarct LVP over a10-year period.

Materials and methods

Between January 2006 through August 2016, a total of 13 patients underwent operation for post infarct pseudoaneurysm of the left ventricle. There were 10 men and 3 women and the mean age was 61 ± 7.6 years. 4 patients presented acute LVP. Two patients had preoperative intraortic balloon pump implantation.

Results

Various surgical techniques were used to obliterate the pseudoaneurysm such as direct pledgeted sutures buttressed by polytetrafluoroethylene felt, a Gore-Tex or Dacron patch, transatrial closure of LVP neck in submitral pseudoaneurysm, or linear closure in cases presenting associated postinfarct ventricular septal defect. Concomitant coronary artery bypasses were performed for significant stenoses in 12 patients, ventricular septal defect closure in 4 patients, mitral valve replacement in 3 and aortic valve replacement in 1 patient. Operative mortality was 30.8% (4 patients). Three of them were acute LVP. Three patients required the continuous hemodyalisis and 8 patients required intra-aortic balloon pump. At follow-up two deaths occurred at 1 and 3 years after surgery.

Conclusion

In conclusion, this study revealed that surgical repair of post infarct left ventricular pseudoaneurysm was associated with an acceptable surgical mortality rate, that cardiac rupture did not occur in surgically treated patients.

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Objective: Our experience with post-infarction left ventricular pseudoaneurysms (LVP) and surgical techniques in 13 patients.

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Various techniques: 1) direct pledgeted sutures; 2) single patch; 3) double-patch; 4) pericardial patch through the left atrium.

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Hospital mortality 4 (30.7%). Literature review: 306 patients with LVP undergoing surgery with 21.2% (65 deaths) mortality.

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In conclusion, this study revealed that surgical repair of LVP was associated with an acceptable surgical mortality rate.

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Cardiac rupture did not occur. Various techniques are available and should be considered according to the case presentation.

Extensive Chest Wall Destruction Secondary to a Large Ventricle Pseudoaneurysm: A Surgical Challenge

Left ventricular pseudoaneurysms have become a rare complication of acute myocardial infarction, occurring in approximately 2% of cases and even less frequently when primary percutaneous intervention can be performed. Regardless of treatment strategy, left ventricle pseudoaneurysms are associated with a high mortality rate. We report on the extremely rare occurrence of a patient surviving two episodes of free wall rupture associated with extensive chest wall destruction and secondary traumatic rib fractures. The key to success in this case is related to both the cardiac and chest wall repair.

Left Ventricular Pseudoaneurysm Following Inferior Myocardial Infarction: A Case for Conservative Management

Left ventricular pseudoaneurysm is a rare complication of myocardial infarction that carries a high mortality rate. Although conventional wisdom suggests prompt surgical repair in order to mitigate risk of expansion and rupture, there are some data to support non-operative management in asymptomatic individuals with likely chronic pseudoaneurysms, particularly when surgical candidacy is poor. We present a case of a medically managed left ventricular pseudoaneurysm subsequent to inferior ST-segment elevation myocardial infarction with 6-month follow-up data.

Multislice computed tomography-guided surgical repair of acquired posterior left ventricular aneurysms: demonstration of mitral valve and left ventricular reverse remodelling

OBJECTIVES

Involvement of the mitral valve (MV) apparatus represents a challenge in surgical ventricular repair (SVR) of posterior left ventricular (LV) aneurysms. This study sought to investigate whether multislice computed tomography (MSCT) assessment can be used to optimize the surgical procedure for posterior LV aneurysms.

METHODS

Thirty patients (m : w = 24 : 6, age 38-78, median 66 years; mean New York Heart Association class 2.98) with posterior LV aneurysm were operated upon. MSCT was performed in 24 patients before and after surgery. End-diastolic and end-systolic volumes of LV and aneurysm were indexed to body surface area (LVEDVI/LVESVI, AEDVI/AESVI). The MV apparatus was characterized by coaptation distance (CD), tenting area (TA), MV closure angle (MVCA), MV annulus area (MVAA) and interpapillary muscle distance (IMD).

RESULTS

Thirty-day mortality was 10% and 5-year survival rate was 83%. After surgery, LVEDVI decreased from 151.2 ± 84.1 to 85.7 ± 28.3 ml/m(2) (P = 0.001) and LVESVI from 110.6 ± 88.8 to 50.2 ± 22.9 ml/m(2) (P = 0.001). LV ejection fraction increased from 31.5 ± 15.1 to 43.4 ± 9.9% (P = 0.001). Preoperative MSCT showed significantly higher values of MVAA, CD and TA in patients who needed MV repair or replacement. Postoperative reduction of mitral regurgitation in patients without MV surgery corresponded with significant reduction in intercommissural diameter, anteroposterior diameter, MVAA, TA, CD, MVCA and IMD.

CONCLUSIONS

MSCT represents an excellent diagnostic tool for the assessment of MV and LV geometry. MSCT-guided SVR of submitral LV aneurysms leads to excellent mid-term results. On the basis of the MSCT assessment, we propose an algorithm for surgical planning in posterior LV aneurysms.