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Surgical treatment of huge left ventricular outflow tract pseudoaneurysm

Surgical treatment of huge left ventricular outflow tract pseudoaneurysm Abstract Pseudoaneurysms arising from the left ventricular outflow tract are rarely reported. We report a 26-year-old man who was admitted with paroxysmal chest pain and dyspnoea on exertion. Computed tomography revealed the presence of a pseudoaneurysm (93 × 77 mm), and the communication was below the aortic annulus. Through median sternotomy, a huge pulsatile pseudoaneurysm was exposed, and an 8-mm-diameter communication of the pseudoaneurysm in the left ventricular outflow tract wall was visualized. The defect was successfully repaired, and the postoperative course was uneventful. Left ventricular outflow tract pseudoaneurysm , Surgical treatment INTRODUCTION Pseudoaneurysms arising from the left ventricular outflow tract (LVOT) are a rare entity, and most cases that have been reported were complications following aortic valve replacement [1], while chest trauma and infective endocarditis were also reported to be responsible for its occurrence [2, 3]. Because of the scarce incidence of this disease, asymptomatic patients or those with atypical symptoms are difficult to be diagnosed accurately and timely. We present a case of a huge LVOT pseudoaneurysm with a suspicious history of endocarditis and its successful surgical treatment. CASE REPORT A 26-year-old man was admitted with paroxysmal chest pain since 4 years and dyspnoea on exertion for the last 4 months. He had a history of prolonged fever 4 years ago, and pericardial effusion was noticed at that time. A local hospital suspected it as tuberculous pericarditis, after pericardiocentesis and empirical antituberculosis treatment, his fever subsided. Half a year later, echocardiography indicated an intrapericardial mass, which enlarged gradually afterwards. On examination, blood pressure was 127/62 mmHg, and cardiac auscultation revealed a soft systolic murmur in the left 3rd to 4th intercostal space. Transthoracic echocardiography showed the bicuspid aortic valve with normal function, and a huge (67 × 76 mm) echo-free pouch around the right aortic root, communicating with the aorta through a 7-mm diameter defect near the right commissure. To clarify the location of the communication, the patient underwent multidetector computed tomography (MDCT). MDCT confirmed the presence of the pseudoaneurysm (93 × 77 mm), but the communication was below the aortic annulus, near the membranous ventricular septum (Fig. 1). No thrombus was identified inside the pseudoaneurysm. Coronary angiography showed no compression of coronary arteries. Figure 1: View largeDownload slide Computed tomography showing a huge pseudoaneurysm. The communication of the pseudoaneurysm was below the aortic valve annulus. The white arrow indicates the communication, and the black arrow indicates the aortic valve. Figure 1: View largeDownload slide Computed tomography showing a huge pseudoaneurysm. The communication of the pseudoaneurysm was below the aortic valve annulus. The white arrow indicates the communication, and the black arrow indicates the aortic valve. Median sternotomy was performed. Severe pericardial adhesion was observed, and adhesiolysis was performed. A huge pulsatile pseudoaneurysm was exposed, and it was located on the right side of the aortic root, overlying the entire right atrium and some part of the right ventricle (Fig. 2A). The aneurysm wall was extensively calcified. Cardiopulmonary bypass was instituted through the ascending aorta and vena cava cannulation. After antegrade cardioplegia, the pseudoaneurysm was entered, and no thrombus was found. An 8-mm-diameter communication of the pseudoaneurysm in the LVOT wall was visualized (Fig. 2B). After the aorta was opened, we confirmed that the communication was just beneath the anterior commissure of aortic valve, and its border was fibrotic and calcified. No vegetation was found, and the membranous ventricular septum was intact. From the pseudoaneurysm, an autologous pericardial patch was sutured by a single running suture of 5-0 polypropylene and reinforced by everted horizontal mattress sutures. The patient was easily weaned off bypass, and transoesophageal echocardiography showed no residual shunt. The cardiopulmonary bypass time was 120 min, and the clamping time was 58 min. Postoperative course was uneventful, and the patient was discharged on the 7th postoperative day. Postoperative MDCT showed that the communication was closed, and the pseudoaneurysm was filled with thrombus (Supplementary Material, Fig. S1). Histopathological examination revealed that the pseudoaneurysm wall was composed of calcified collagen fibres, and no myocardium tissue was identified. Figure 2: View largeDownload slide (A) The pseudoaneurysm overlied the entire right atrium and some parts of the right ventricle. The asterisks indicate the border of the pseudoaneurysm. (B) The anterior wall of the pseudoaneurysm was cut. The arrow indicates the communication of the pseudoaneurysm in the left ventricular outflow tract. Figure 2: View largeDownload slide (A) The pseudoaneurysm overlied the entire right atrium and some parts of the right ventricle. The asterisks indicate the border of the pseudoaneurysm. (B) The anterior wall of the pseudoaneurysm was cut. The arrow indicates the communication of the pseudoaneurysm in the left ventricular outflow tract. DISCUSSION The rarity of LVOT pseudoaneurysms makes it difficult to have the correct diagnosis initially. In this case, echocardiography indicated an aortic pseudoaneurysm in the beginning. MDCT or magnetic resonance imaging (MRI) is essential to identify the location of communication, which is very important for the surgical strategy. Differentiation of the left ventricular pseudoaneurysm and true aneurysm could be very challenging. For this patient, before surgery, the global and regional function of the left ventricle was normal according to the echocardiography and MRI. The histopathological workup showed that there was no myocardium in the excised tissue, which ruled out the diagnosis of the left ventricular true aneurysm. The aetiology of the LVOT pseudoaneurysm includes endocarditis, trauma and suture dehiscence following aortic valve replacement. For this patient, considering the history of prolonged fever, endocarditis was the most possible cause. Surgical repair for this disease is safe, effective and definite. Percutaneous coil embolization has been reported to be an effective alternative for open heart surgery in selected patients [4]. SUPPLEMENTARY MATERIAL Supplementary material is available at ICVTS online. Conflict of interest: none declared. REFERENCES 1 Tsai IC , Hsieh SR , Chern MS , Huang HT , Chen MC , Tsai WL et al. Pseudoaneurysm in the left ventricular outflow tract after prosthetic aortic valve implantation: evaluation upon multidetector-row computed tomography . Tex Heart Inst J 2009 ; 36 : 428 – 32 . Google Scholar PubMed 2 Aktuerk D , Lutz M , Giri R , Matuszewski MJ. Delayed presentation of a traumatic bilobed pseudoaneurysm of the left ventricular outflow tract . Eur Heart J Cardiovasc Imaging 2014 ; 15 : 995. Google Scholar CrossRef Search ADS PubMed 3 Vijay SK , Saran RK , Ameta D , Sethi R , Chandra S , Dwivedi SK et al. Giant multiloculated left ventricular outflow tract pseudoaneurysm causing severe extrinsic compression of subpulmonic infundibulum . Circulation 2013 ; 127 : e618 – 21 . Google Scholar CrossRef Search ADS PubMed 4 Ota H , Morita Y , Saiki Y , Takase K. Coil embolization of left ventricular outflow tract pseudoaneurysms: techniques and 5-year results . Interact CardioVasc Thorac Surg 2017 ; 24 : 631 – 3 . Google Scholar PubMed © The Author(s) 2018. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved. This article is published and distributed under the terms of the Oxford University Press, Standard Journals Publication Model (https://academic.oup.com/journals/pages/about_us/legal/notices) http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Interactive CardioVascular and Thoracic Surgery Oxford University Press

Surgical treatment of huge left ventricular outflow tract pseudoaneurysm

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© The Author(s) 2018. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.
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Abstract

Abstract Pseudoaneurysms arising from the left ventricular outflow tract are rarely reported. We report a 26-year-old man who was admitted with paroxysmal chest pain and dyspnoea on exertion. Computed tomography revealed the presence of a pseudoaneurysm (93 × 77 mm), and the communication was below the aortic annulus. Through median sternotomy, a huge pulsatile pseudoaneurysm was exposed, and an 8-mm-diameter communication of the pseudoaneurysm in the left ventricular outflow tract wall was visualized. The defect was successfully repaired, and the postoperative course was uneventful. Left ventricular outflow tract pseudoaneurysm , Surgical treatment INTRODUCTION Pseudoaneurysms arising from the left ventricular outflow tract (LVOT) are a rare entity, and most cases that have been reported were complications following aortic valve replacement [1], while chest trauma and infective endocarditis were also reported to be responsible for its occurrence [2, 3]. Because of the scarce incidence of this disease, asymptomatic patients or those with atypical symptoms are difficult to be diagnosed accurately and timely. We present a case of a huge LVOT pseudoaneurysm with a suspicious history of endocarditis and its successful surgical treatment. CASE REPORT A 26-year-old man was admitted with paroxysmal chest pain since 4 years and dyspnoea on exertion for the last 4 months. He had a history of prolonged fever 4 years ago, and pericardial effusion was noticed at that time. A local hospital suspected it as tuberculous pericarditis, after pericardiocentesis and empirical antituberculosis treatment, his fever subsided. Half a year later, echocardiography indicated an intrapericardial mass, which enlarged gradually afterwards. On examination, blood pressure was 127/62 mmHg, and cardiac auscultation revealed a soft systolic murmur in the left 3rd to 4th intercostal space. Transthoracic echocardiography showed the bicuspid aortic valve with normal function, and a huge (67 × 76 mm) echo-free pouch around the right aortic root, communicating with the aorta through a 7-mm diameter defect near the right commissure. To clarify the location of the communication, the patient underwent multidetector computed tomography (MDCT). MDCT confirmed the presence of the pseudoaneurysm (93 × 77 mm), but the communication was below the aortic annulus, near the membranous ventricular septum (Fig. 1). No thrombus was identified inside the pseudoaneurysm. Coronary angiography showed no compression of coronary arteries. Figure 1: View largeDownload slide Computed tomography showing a huge pseudoaneurysm. The communication of the pseudoaneurysm was below the aortic valve annulus. The white arrow indicates the communication, and the black arrow indicates the aortic valve. Figure 1: View largeDownload slide Computed tomography showing a huge pseudoaneurysm. The communication of the pseudoaneurysm was below the aortic valve annulus. The white arrow indicates the communication, and the black arrow indicates the aortic valve. Median sternotomy was performed. Severe pericardial adhesion was observed, and adhesiolysis was performed. A huge pulsatile pseudoaneurysm was exposed, and it was located on the right side of the aortic root, overlying the entire right atrium and some part of the right ventricle (Fig. 2A). The aneurysm wall was extensively calcified. Cardiopulmonary bypass was instituted through the ascending aorta and vena cava cannulation. After antegrade cardioplegia, the pseudoaneurysm was entered, and no thrombus was found. An 8-mm-diameter communication of the pseudoaneurysm in the LVOT wall was visualized (Fig. 2B). After the aorta was opened, we confirmed that the communication was just beneath the anterior commissure of aortic valve, and its border was fibrotic and calcified. No vegetation was found, and the membranous ventricular septum was intact. From the pseudoaneurysm, an autologous pericardial patch was sutured by a single running suture of 5-0 polypropylene and reinforced by everted horizontal mattress sutures. The patient was easily weaned off bypass, and transoesophageal echocardiography showed no residual shunt. The cardiopulmonary bypass time was 120 min, and the clamping time was 58 min. Postoperative course was uneventful, and the patient was discharged on the 7th postoperative day. Postoperative MDCT showed that the communication was closed, and the pseudoaneurysm was filled with thrombus (Supplementary Material, Fig. S1). Histopathological examination revealed that the pseudoaneurysm wall was composed of calcified collagen fibres, and no myocardium tissue was identified. Figure 2: View largeDownload slide (A) The pseudoaneurysm overlied the entire right atrium and some parts of the right ventricle. The asterisks indicate the border of the pseudoaneurysm. (B) The anterior wall of the pseudoaneurysm was cut. The arrow indicates the communication of the pseudoaneurysm in the left ventricular outflow tract. Figure 2: View largeDownload slide (A) The pseudoaneurysm overlied the entire right atrium and some parts of the right ventricle. The asterisks indicate the border of the pseudoaneurysm. (B) The anterior wall of the pseudoaneurysm was cut. The arrow indicates the communication of the pseudoaneurysm in the left ventricular outflow tract. DISCUSSION The rarity of LVOT pseudoaneurysms makes it difficult to have the correct diagnosis initially. In this case, echocardiography indicated an aortic pseudoaneurysm in the beginning. MDCT or magnetic resonance imaging (MRI) is essential to identify the location of communication, which is very important for the surgical strategy. Differentiation of the left ventricular pseudoaneurysm and true aneurysm could be very challenging. For this patient, before surgery, the global and regional function of the left ventricle was normal according to the echocardiography and MRI. The histopathological workup showed that there was no myocardium in the excised tissue, which ruled out the diagnosis of the left ventricular true aneurysm. The aetiology of the LVOT pseudoaneurysm includes endocarditis, trauma and suture dehiscence following aortic valve replacement. For this patient, considering the history of prolonged fever, endocarditis was the most possible cause. Surgical repair for this disease is safe, effective and definite. Percutaneous coil embolization has been reported to be an effective alternative for open heart surgery in selected patients [4]. SUPPLEMENTARY MATERIAL Supplementary material is available at ICVTS online. Conflict of interest: none declared. REFERENCES 1 Tsai IC , Hsieh SR , Chern MS , Huang HT , Chen MC , Tsai WL et al. Pseudoaneurysm in the left ventricular outflow tract after prosthetic aortic valve implantation: evaluation upon multidetector-row computed tomography . Tex Heart Inst J 2009 ; 36 : 428 – 32 . Google Scholar PubMed 2 Aktuerk D , Lutz M , Giri R , Matuszewski MJ. Delayed presentation of a traumatic bilobed pseudoaneurysm of the left ventricular outflow tract . Eur Heart J Cardiovasc Imaging 2014 ; 15 : 995. Google Scholar CrossRef Search ADS PubMed 3 Vijay SK , Saran RK , Ameta D , Sethi R , Chandra S , Dwivedi SK et al. Giant multiloculated left ventricular outflow tract pseudoaneurysm causing severe extrinsic compression of subpulmonic infundibulum . Circulation 2013 ; 127 : e618 – 21 . Google Scholar CrossRef Search ADS PubMed 4 Ota H , Morita Y , Saiki Y , Takase K. Coil embolization of left ventricular outflow tract pseudoaneurysms: techniques and 5-year results . Interact CardioVasc Thorac Surg 2017 ; 24 : 631 – 3 . Google Scholar PubMed © The Author(s) 2018. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved. This article is published and distributed under the terms of the Oxford University Press, Standard Journals Publication Model (https://academic.oup.com/journals/pages/about_us/legal/notices)

Journal

Interactive CardioVascular and Thoracic Surgery – Oxford University Press

Published: Apr 12, 2018

References

  • Pseudoaneurysm in the left ventricular outflow tract after prosthetic aortic valve implantation: evaluation upon multidetector-row computed tomography
    Tsai
  • Delayed presentation of a traumatic bilobed pseudoaneurysm of the left ventricular outflow tract
    Aktuerk
  • Giant multiloculated left ventricular outflow tract pseudoaneurysm causing severe extrinsic compression of subpulmonic infundibulum
    Vijay
  • Coil embolization of left ventricular outflow tract pseudoaneurysms: techniques and 5-year results
    Ota