CLINICAL SUMMARY
A 45-year-old male with a known history of non-ischemic cardiomyopathy (NICM) presented with prolonged episodes of ventricular tachycardia (VT). The patient was initially diagnosed with NICM at the age of 2 and has struggled with recurrent episodes of non-sustained polymorphic ventricular tachycardia since the age of 42 resulting in placement of an implantable cardioverter-defibrillator (ICD) for secondary prevention. The patient was also found to have a large sized calcified apical aneurysm on computed tomography (Figure 1A) and magnetic resonance imaging of the heart. His echocardiogram on presentation revealed a severe decrease in his left ventricular (LV) systolic function. His coronary angiogram did not reveal any significant coronary artery disease. The patient underwent attempts at epicardial and endocardial ablation of his VT but those were of no avail and failure was attributed to adhesions from his heavily calcific apical LV aneurysm. Nonetheless, the area suspect of arrhythmia generation was marked by electrophysiology team. The patient’s other past medical history includes hypertension, dyslipidemia, and atrial fibrillation. He is also an active smoker. The options for treatment were discussed with the patient and the cardiac team, including surgery or continuing pharmacological and electrical cardioversion therapy, while also listing him for heart transplantation. The cardiac team and the patient agreed that surgery should be attempted given the multiple failed non-operative management efforts. After informed consent was obtained, the patient was taken to the operating room for left ventricular aneurysm resection and cryoablation.
The surgery was performed through a median sternotomy. After systemic heparinization, we routinely cannulated his distal ascending aorta and the right atrium. The patient was placed on cardiopulmonary bypass and maintained warm. An LV vent was then engaged in the right superior pulmonary vein. We then cross-clamped the aorta and arrested the heart using antegrade cardioplegia with warm induction followed by cold intermittent cardioplegia. We then exposed the LV apex and found a heavily calcified aneurysm. The aneurysm which was adhered to the pericardium, was carefully mobilized. We opened the aneurysm sac and enucleated the calcified cap in order to get suture needles through the tissue. We did not resect the fibrous tissue to facilitate closure and hemostasis. We used cryoablation (Cardioblate CryoFlex surgical ablation Probe, Medtronic, Minneapolis, USA) to ablate both the endocardium and epicardium at the junction between the normal myocardium and fibrous tissue to ensure a transmural isolation. A Fontan suture was placed around the neck of the LV aneurysm and was tied around a 150 ml normal saline filled balloon which was stationed in the LV cavity. We then used a triangular bovine pericardial patch measuring 2.5 x 3cm to close the aneurysm neck and used felt from each side of the aneurysm to close the tissues of the apex over the patch in 2 layers. We then placed BioGlue onto that area to reinforce hemostasis. The patient was weaned off bypass with no difficulty. The surgery was completed with no complications and the patient was transferred to the Intensive Care Unit in stable condition.
The patient remained hemodynamically stable postoperatively, and was extubated on the first post-operative day. He was found to have no ventricular tachycardia following his surgery with only occasional premature ventricular contractions (PVC). He was deemed safe to be transferred to the floor by our electrophysiology colleagues. He mobilized himself very quickly and was discharged home on the 6th post-operative day. At 2-months follow-up, the patient was still doing well from a clinical standpoint with CCS class 0 and NYHA class II symptoms. At 12-month follow-up, his echocardiography and computed tomography images (Figure 1B) revealed significantly reduced LV diastolic dimensions and volumes. The LV ejection fraction rose to 55% from 25% preoperatively. Interrogation of the patient’s ICD showed PVCs, but no ventricular tachycardia.