Acquired left ventricular pseudoaneurysm is a rare disorder that
occurs after acute myocardial infarction. We present a 55 year-old male
patient with a nonruptured pseudoaneurysm after acute MI presenting with
severe mitral regurgitation. After resection of sac-like lesion, the
defect was 5 cm diameter posterolaterally left ventricular. The aneursym
was repaired with pericardium patch to maintain cardiac geometry that
diminishes mitral regurgitation without intervention to mitral valve.
IntroductionLeft ventricular pseudoaneurysm is a rare complication of acute
myocardial infarction that can result with catastrophic conditions. We
present a 55 year-old male patient with a nonruptured pseudoaneurysm
after acute MI presenting with severe mitral regurgitation due to the
localisation of defect.
Surgical resection of the sac and repair of the ventricle was performed
with bovine pericardium, also left internal mammary artery (ITA) to left
anterior descending (LAD) artery bypass performed.
This article is based on previously conducted studies and does not
contain any studies with human participants or animals performed by any
of the authors. Informed consent has been taken by the patient and the
study has been approved by the ethics committee of our
hospital.Case ReportA 55 year-old male patient presented to our clinic with dyspnea and
palpitation that get worse for couple of weeks. He has a history of
hypertension, diabetes mellitus and chronic obstructive pulmonary
disease. His blood pressure was 110/70 mm Hg, pulse rate 90 with sinus
ryhtm. Transthoracic echocardiography showed 40-45% of ejection
fraction, mild pericardial effusion, severe mitral regurgitation and the
impairment on left ventricular segmental wall motion with a dyskinetic
cavity posterolaterally. Color doppler showed passage of blood from left
ventricular cavity to pericardium with and narrow opening. CT-
Angiography revealed a 5 x 5.5 cm sized focal sac like lesion next to
posterolateral left ventricular wall with 2 cm neck. [Figure
1 ] Patient underwent coronary angiography, that showed 80 % lesion
on proximal LAD, total occlusion on circumflex artery and 70% lesion on
right coronary artery (RCA).
At surgery, a large nonruptured posterolateral pseudoaneurysm was seen.
After resection of the sac, the defect was between two papillary muscle
on posterior left ventricle was closed with bovine pericardium patch
strengthened with teflon-felt pledgets [Figure 2 ].
Concomitant Left ITA to LAD bypass were performed. Circumflex artery was
not bypass-able and RCA could not be visualisized due to adhesions.
Intraaortic balloon pump was placed perioperatively. Control
transesophageal echocardiography showed no outflow from the defect and
mild mitral regurgitation was detected without need of mitral valve
intervention and the operation was completed.
Postoperatively, the patient was taken to the intensive care unit, was
extubated on the 2nd day of his follow-up,
hemodynamically stable. Safely separated from intraaortic balloon pump
after the control transtorasic echocardiography reported as %35-40 of
ejection fraction, mild mitral insufficiency and postero-septal
hipokinesia. Unfourtunately he was re-intubated 5thday due to respiratory disstress. Examinations showed up he has Covid-19
infection. Due to respiratory failure the patient deceased
8th day
post-operation.DiscussionLeft ventricular rupture is a rare mechanical complication that seen
after acute myocardial infarction. Free wall rupture causes sudden
death. Rarely the rupture of the ventricle is limited with adherent
fibrous pericardial tissue that results as pseudoaneurysm formation.
Pseudoaneurysms are characterized by a neck narrower than the diameter
of the sac which contains organized trombus and blood with no
myocardium. This is in contrast to true aneurysm, which have wider neck
and progresses from endocardium to pericardium respectively [1].
Acute transmural MI is the most common cause of LV pseudoaneurysm
(%55); followed by cardiac surgery (%33), trauma (%7) and infection
(%5)[2]. About half of the pseudoaneurysms were posterior or
inferior localisation. [3] Pseudoaneurysm have an approximately
30-40% risk of rupture and also embolism, arhytmia that can result
catastrophic conditions.Two-dimensional transthoracic echocardiography
and left ventriculography are the best available test for the diagnosis.
Coronary angiography findings may help distinguish the source of
ischemia. Also CT-Angiography and cardiac MRI provide detailed images of
the pseudoaneurysm and delineates its relation to other cardiac
structures. [4] Early surgical intervention with patch closure is
recommended once the pseudoaneurysm is detected because of the high risk
of rupture.
Mitral failure associated with pseudoaneurysm is caused by mainly three
factors: mitral ring dilatation, restriction of posterior mital leaflet
due to ventricular dilatation, loss of contraction of ventricular wall.
[7] Repair of pseudoaneurysm as in this case, may support to
restoration of ventricular geometry and reestablishing mitral valvar
function.ConclusionsLeft ventricular wall rupture is a mortal complication occuring 4% of
patients after acute MI [5]. Rarely pseudoaneurysm information can
be seen with adherent pericardial tissue. Pseudoaneurysms can be
symptomatic or may also have silent progress, require suspicious
examination. Once it diagnosed, it should be corrected urgently because
of the high risk of complication such as heart failure, embolism or
sudden death. During procedure maintaining cardiac geometry is crucial
for proper cardiac physiology. [6] And this case have shown that the
mitral insufficiency which was thought to be related to the LV
pseudoaneurysm can be corrected with repair of the pseudoaneurysm and
may not require mitral intervention.