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.