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Abstract(Please copy/paste the abstract send to the congress) : |
Background:
Left ventricular pseudoaneurysm is an extremely rare but lethal condition which could complicate patients after myocardial infarction, cardiac surgery, trauma or infection. We describe a 57-year old man who developed recurrent infected pseudoaneurysm after a ventriculotomy for a left ventricular aneurysm.
Case report:
A 57 year-old man with the diagnosis of unstable angina was admitted to the hospital. He underwent angiography which demonstrated three-vessel coronary artery disease, and a transthoracic echocardiography which revealed a left ventricular apical aneurysm with thrombus. For this reason, left ventriculorraphy and coronary artery bypass grafting were performed concomitantly. patient was discharged home 10 days after the procedure in good general condition.
Two months later, patient was re-admitted, complaining of difficulty breathing, dyspnea on exertion and fatigue. Transthoracic echocardiography showed massive pericardial effusion.
In addition, a large apical pseudoaneurysm (53×39mm) with a narrow neck was detected which was suggestive of postoperative pseudoaneurysm of the left ventricle.
Second operation was carried out through left lateral thoracotomy. After adhesiolysis, Teflon felt was removed, and aneurysmorrhaphy was performed using a GORE-TEX® patch. Teflon felt culture demonstrated staphylococcus aureus infection .
After about 1 month, he came back again with the complaint of fluid leaking through the thoracotomy incision site. Transthoracic echocardiography showed a narrow-neck left ventricular pseudoaneurysm following dehiscence of the previous stitches. Culture of fluid from the thoracotomy incision confirmed staphylococcus aureus infection. Initially, we tried to close the defect with an Amplatzer occluder device; however, patient’s condition became worse over the next 48 hours. Therefore, a transthoracic echocardiography and a computed tomography (CT-scan) with contrast were performed, and showed a floating Amplatzer in the left ventricle following the enlargement of the pseudoaneurysm.
Consequently, patient was prepared for the third operation via anterior thoracotomy. First, the pseudoaneurysm was exposed, and the Amplatzer was removed. After resection of necrotic tissue and debris, and trimming of the opening of the pseudoaneurysm, endoaneurysmorrhaphy was performed. An omental flap was used to cover the defect. One week later, patient was discharged in fair condition.
After a fortnight, patient was brought to our department with a high grade fever (39.5 ̊C oral) and severe respiratory distress. A giant left ventricular pseudoaneurysm was found on transthoracic echocardiography. In order to surgical repair of the lesion, fourth operation was carried out via midsternotomy using cardiopulmonary bypass. An autologous pericardial patch was used to reconstruct the defect, but unfortunately, patient died soon after the operation. His death was mainly due to low cardiac output caused by multiple debridement of the left ventricle.
Previous cardiac surgery has been considered as the second most common cause of left ventricular pseudoaneurysm. Postsurgical pseudoaneurysm rarely occurs after cardiac procedures including mitral valve replacement or after ventriculotomy ; however, its natural course has not yet been well characterized due to rarity . In this case, both previous ventriculotomy and infection are contributing factors for recurrent pseudoaneurysm. There are a limited number of reported cases of recurrent left ventricular pseudoaneurysm, but to our knowledge, our case is different in regard to the rate and number of relapses and its rapid progress. In contrast to this patient whose pseudoaneurysm recurred just1 month after the first pseudoaneurysm repair, the previously reported patients had been free of symptoms for years after the initial repair. |