Abstract

Key Points

• Left ventricular pseudoaneurysm is a serious and rare complication that develops after acute myocardial infarction.

• Surgical repair of left ventricular pseudoaneurysm involves reconstructing the left ventricle with the goal of restoring normal cardiac geometry.

• Concomitant coronary artery revascularization may be valuable in maintaining left ventricular function..

Abbreviations and Acronyms

LV

left ventricular

MI

myocardial infarction

Case Report

Presentation and Physical Examination

A 64-year-old man was admitted to the emergency department for progressive dyspnea on exertion. He had experienced myocardial infarction (MI) 1 month earlier, but because of the COVID-19 pandemic, he had refused hospitalization out of fear of infection. Transthoracic echocardiography revealed severe left ventricular (LV) dysfunction, global hypokinesia, and a large LV aneurysm containing a thrombus. The patient’s ejection fraction was 22% (Fig. 1A). He was taken to the cardiac catheterization laboratory, where multivessel coronary artery disease was diagnosed (Fig. 1B). Cardiac magnetic resonance imaging, which was performed to evaluate LV function and characterize the myocardium, revealed an extensive inferolateral wall infarct with free wall rupture into a huge pseudoaneurysm sac that contained a large thrombus (Fig. 1C).

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Technique

The patient underwent surgical correction of the LV pseudoaneurysm, which measured approximately 9 × 8 × 7 cm and adhered tightly to the pericardium and left visceral pleura (Fig. 2). After ventriculotomy to access the LV apex, an old thrombus and long-standing hematoma were extracted. A 5 × 3-cm defect was found that was closed with a bovine pericardial patch (Fig. 3). With 2 layers of 3-0 Prolene (Ethicon) continuous suture, a transition zone was established between the healthy myocardium and areas of fibrosis. The ventriculotomy site was repaired with 2 mattress sutures supported with Teflon felt and sealed and reinforced with 3-0 Prolene sutures and surgical glue (Fig. 4). In the concomitant coronary artery bypass grafting procedure, the left internal thoracic artery was anastomosed to the left anterior descending coronary artery, and the great saphenous vein was anastomosed to the distal right coronary artery (Fig. 5).

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The patient’s postoperative course was uneventful. He was extubated 1 day after surgery and discharged 18 days after surgery without complications.

Discussion

Left ventricular pseudoaneurysm is a rare disorder that typically develops after transmural MI.¹ The incidence of post-MI complications has statistically significantly decreased since the development and wide adoption of percutaneous coronary intervention and medications,² but it remains a potentially lethal mechanical complication when associated with acute LV free wall rupture. In pathologic terms, LV pseudoaneurysm is characterized by a small channel with a narrow neck connecting the ventricle to a larger aneurysmal sac; that sac contains blood and thrombus, and it is lined with fibrous pericardial tissue but no myocardial elements.³ These pseudoaneurysms differ from true ventricular aneurysms in that they include no endocardium or myocardium and are more likely to expand and rupture.⁴

Diagnosis is complicated because the most frequently reported symptoms are heart failure, chest pain, and dyspnea, which are common in patients with coronary artery disease. Advances in noninvasive imaging have made it easier to distinguish pseudoaneurysm from other pathologies, leading to more timely management.⁵ Transthoracic echocardiography is usually the preferred imaging modality because it is readily available and fast. Cardiac magnetic resonance imaging is an excellent diagnostic modality that identifies the contained cardiac rupture and provides clear anatomic images to guide surgical intervention.

Surgical techniques for correcting an LV pseudoaneurysm aim to reconstruct the left ventricle or reduce its volume, with the goal of restoring normal cardiac geometry and repairing the weakened LV wall. Historically, the surgical technique of intracavitary repair known as endoventricular circular plasty was the standard method of LV pseudoaneurysm repair, as described by Dor et al.⁶

Surgical technique should be adapted to each patient’s anatomic characteristics, including cavity size and shape, scar dimension, and septal involvement. In the present case, the pseudoaneurysm had a sac measuring approximately 9 × 8 × 7 cm, with a 5 × 3-cm defect neck, and the transition area had been considerably widened. Thus, normal LV geometry was reproduced by using a bovine pericardial patch to restore the ventricle’s elliptical shape. Cooley⁷ repaired ventricular aneurysms with ventricular endoaneurysmorrhaphy, in which a tailored Dacron patch is used to make the length and width of the left ventricle conform to its normal volume. This technique emphasizes restoring function rather than excising diseased tissue.⁷ In contrast, bovine pericardial patches are preferred because of their elasticity and ease of use and because they appear to allow less bleeding at the suture site than a Dacron patch. The main goals of surgery are to return the left ventricle to a more normal volume and shape, restore wall integrity, exclude akinetic segments of the myocardium, and reduce the endocardial nidus for thrombus formation.⁸

In this patient, concomitant coronary revascularization was performed by anastomosing (1) the left internal thoracic artery to the left anterior descending coronary artery and (2) the great saphenous vein to the distal right coronary artery. Complete myocardial revascularization during left ventricle–restoring surgery may be valuable because it allows ventricles already at risk to better support the overall circulation, particularly in patients with low ejection fraction.

This case of LV pseudoaneurysm after MI was discovered during the COVID-19 pandemic lockdown. Because patients with LV pseudoaneurysm have a high mortality rate, early diagnosis is important. When a diagnosis is made, as in this case, surgical ventricular restoration can improve ventricular function and functional status, producing a satisfactory outcome. In addition, concomitant coronary artery revascularization may improve outcomes by supporting LV function.