Case
A 47-year-old male patient came to our hospital with an acute onset of
chest pain and was diagnosed with anterior wall myocardial infarction
(MI) which was managed conservatively. Four weeks later he came to his
physician with a complaint of heaviness in chest since 12 hrs.
Transthoracic echocardiogram (TTE) revealed a large 12x10cm
pseudoaneurysm located at the left ventricular (LV) apex that
communicated with the pericardial cavity through a 24mm defect (Figure
1; Video 1). Flow across the defect was confirmed by color flow Doppler
(Figure 2; Video 2). Coronary angiography revealed complete occlusion of
the left anterior descending artery. Emergency surgery was planned in
view of massive LV pseudoaneurysm. After the induction of anesthesia, a
median sternotomy was done. A large LV apical pseudoaneurysm was
visualized which was contained by a thick, densely adherent fibrous
capsule of the pericardium. The Cardiopulmonary bypass (CPB) was
initiated after systemic heparinization. After aortic cross-clamp, a
complete dissection of the heart was performed, to avoid systemic
embolization. Antegrade cold blood cardioplegia was delivered to arrest
the heart. The aneurysm sac was opened by a longitudinal incision
(Figure 3). The defect was located close to the apex of the LV, which
was closed with a Gore-Tex patch to avoid possible distortion of the
heart structures. Bioglue was applied over it and the patient was taken
off bypass. The CPB was terminated with ionotropic support of milrinone
0.4mcg/kg/min and noradrenaline of 0.05mcg/kg/min. The patient was
successfully shifted to the intensive care unit with stable hemodynamics
and the trachea was extubated after 24 hours. A written informed consent
was taken from the patient and the case was approved by the
institutional review board.