Cardiovascular Journal of Africa: Vol 25 No 5 (September/October 2014)

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CARDIOVASCULAR JOURNAL OF AFRICA • Volume 25, No 5, September/October 2014 AFRICA e1
Case Report
Surgical treatment of post-infarct left ventricular pseudo-
aneurysm with on-pump beating heart technique
Kemal Korkmaz, Gökhan Lafçi, Hikmet Selçuk Gedik, Ali Baran Budak, Ali Ümit Yener, Ata Niyazi Ecevit,
Adnan Yalçinkaya, Ersin Kadiroğullari, Kerim Çağli
Abstract
Left ventricular pseudo-aneurysms develop when cardiac
rupture is contained by pericardial adhesions or scar tissue
due to myocardial infarction, surgery, trauma or infection.
Left ventricular pseudo-aneurysms are uncommon, difficult
to diagnose and prone to cardiac rupture. Urgent surgical
repair is recommended. Here we report on a case of a large
left ventricular pseudo-aneurysm on the anterolateral wall
due to a previous anterior myocardial infarction, and its
successful repair using the on-pump beating-heart technique.
Keywords: left ventricular pseudo-aneurysm, repair, on-pump
beating heart
Submitted 1/7/13, accepted 9/5/14
Cardiovasc J Afr 2014; 25: e1–e4
DOI: 10.5830/CVJA-2014-026
Left ventricular (LV) free wall rupture is a fatal complication
of myocardial infarction (MI). Its prevalence is 4% in patients
with MI.1,2 On the other hand, when the cardiac rupture is
unrecognised and contained by pericardial adhesions, organising
thrombus and haematoma, a LV pseudo-aneurysm develops.
Acquired LV pseudo-aneurysms may develop after transmural
MI (55%), surgery (33%), trauma (7%) or infection (5%).3
Since it is a rare complication, the natural progression of
LV pseudo-aneurysm is not well known. When a LV pseudo-
aneurysm is detected, urgent surgical repair is recommended
because of the possibility of complete rupture and the risk of
fatal cardiac tamponade.4 Here we report on a case with a large
LV pseudo-aneurysm on the anterolateral wall due to a previous
anterior MI and its successful repair using the on-pump beating-
heart technique (ONCAB/BH).
Case report
A 62-year-old woman with history of prior anterior MI
presented to our clinic with symptoms of shortness of breath
at rest and palpitations. Five months previously, the patient was
treated with a stent implantation to the left anterior descending
artery (LAD). A chest X-ray showed an enlarged heart with an
aberrant contour in the lateral projection (Fig 1A).
An electrocardiogram examination revealed persistent
ST-segment elevation in leads V2–V4. Echocardiography showed
a 6 × 6 × 4-cm limited mushroom-shaped anechoic area at the
anterolateral wall of the LV, mild mitral valve regurgitation and
severe LV dysfunction with an ejection fraction of 32% (Fig. 1B).
Coronary angiography revealed 90% stenosis of the first
diagonal branch of the LAD and 80% stenosis of the first
obtuse marginal branch of the circumflex artery. There was no
significant stenosis in the LAD.
Urgent surgery was conducted through a median sternotomy.
Standard cannulation of the aorta and right atrium was
done and the operation was carried out using normothermic
cardiopulmonary bypass (CPB). The pseudo-aneurysm extended
to the anterolateral side of the LV wall and was contained by
pericardial adhesion.
The LV was gently dissected free from the pericardium. A
piece of the pericardium was left at the site of the pseudo-
aneurysmal sac. The sac of the pseudo-aneurysm was incised.
There were no clots in the pseudo-aneurysm. The defect in the
myocardium forming the neck of the pseudo-aneurysm was
detected.
The neck of the pseudo-aneurysm was fused with thick, firm
endocardium using separate full-thickness U sutures (Fig. 2A),
and closed by creating a longitudinal plication line, which was
buttressed with Teflon felt strips (Fig. 2B). The necrotic part
of the LV wall was removed (Fig. 2C) and the plication was
strengthened with sutures.
Following surgical repair of the LV pseudo-aneurysm,
sequential coronary artery bypass venous grafting was performed
to the first diagonal branch of the LAD and the first obtuse
marginal branch of the circumflex artery (Fig 2D). The operation
was performed with ther normothermic ONCAB/BH technique.
Department of Cardiovascular Surgery, Ankara Numune
Research and Training Hospital, Ankara, Turkey
Kemal Korkmaz, MD,
Hikmet Selçuk Gedik, MD
Ali Baran Budak, MD
Ali Ümit Yener, MD
Kerim Çağli, MD
Department of Cardiovascular Surgery, Yüksek Ihtisas
Research and Training Hospital, Ankara, Turkey
Gökhan Lafçi, MD
Ata Niyazi Ecevit, MD
Adnan Yalçinkaya, MD
Ersin Kadiroğullari, MD