International Journal of Cardiology 198 (2015) 152–153
Contents lists available at ScienceDirect
International Journal of Cardiology journal homepage: www.elsevier.com/locate/ijcard
Letter to the Editor
Current role of cardiac imaging to guide surgical correction of a giant left ventricular pseudoaneurysm☆ Marcos Garcia-Guimaraes a,⁎, Carlos Velasco-Garcia-de-Sierra b, Francisco Estevez-Cid b, Lucia Perez-Cebey a, Alberto Bouzas-Mosquera a, Elizabet Mendez-Eirin a, Laura Fernandez-Arias b, J.J. Cuenca-Castillo b, J.M. Vazquez-Rodriguez a a b
The Cardiology Department of Complejo Hospitalario Universitario de A Coruña, Spain The Cardiac Surgery Department of Complejo Hospitalario Universitario de A Coruña, Spain
a r t i c l e
i n f o
Article history: Received 25 June 2015 Accepted 27 June 2015 Available online 2 July 2015
Pseudoaneurysm (Ps) is a rare complication after myocardial infarction (MI), even less frequent nowadays in the reperfusion era. Despite that MI is the most frequent cause of this condition, the presence of Ps has been described in the context of other conditions, such as mitral valve replacement, trauma or tumor invasion [1]. The Ps develops when a zone of cardiac rupture is surrounded by the pericardium, associated with an inflammatory and pro-thrombotic process that prevents progression to rupture and cardiac tamponade [2]. Previously the progression of these Ps to rupture in a great percentage of patients, leading to the classical indication of surgical correction, has been described [3]. Non-invasive cardiac imaging constitutes the cornerstone for the diagnosis of this condition, as well as gives valuable information to the cardiac surgery team to guide surgical correction. Here we present a clinical case of a 56 year-old gentleman with a previous history of hypertension and smoking, who was admitted to our institution for an acute episode of chest pain followed by syncope. On admission the patient was still symptomatic and hypotensive (systolic blood pressure of 80 mm Hg). The electrocardiogram showed an image of infero-lateral ST segment elevation myocardial infarction (STEMI). The patient underwent emergent coronary angiogram, which disclosed a 95% stenosis on the second acute marginal branch. The lesion was treated by the implantation of a bare metal stent. As the patient remained hypotensive after the procedure, he was admitted to our Coronary Care Unit. A transthoracic echocardiogram (TTE) revealed severe pericardial effusion and signs of cardiac tamponade. Then, an urgent pericardiocentesis was performed, draining 500 ml of ☆ Disclosures: none. ⁎ Corresponding author at: Complejo Hospitalario Universitario de A Coruña, As Xubias 84, 15006 A Coruña, Spain. E-mail address: [email protected] (M. Garcia-Guimaraes).
http://dx.doi.org/10.1016/j.ijcard.2015.06.129 0167-5273/© 2015 Elsevier Ireland Ltd. All rights reserved.
hemorrhagic effusion. The patient rapidly improved and a new TTE showed no significant pericardial effusion. With the suspicious of a mechanical complication after STEMI, a cardiac magnetic resonance (cMR) was performed, confirming the presence of cardiac rupture located in the infero-lateral wall of the left ventricle evolving to a small Ps. The case was discussed at the heart-team meeting and, as the patient remained stable for days, surgery was initially declined. Our patient was subsequently discharged and referred to be followed-up in our outpatient clinic. Unfortunately, the patient was lost to follow-up as he failed to attend the scheduled appointment. Eight months after the index admission, the patient returned to the emergency department of our institution, due to the acute onset of shortness of breath. On physical examination, the patient showed clear signs of pulmonary congestion. An urgent TTE confirmed the presence of a giant Ps, located on the infero-lateral wall of the left ventricle, with bidirectional flow within and compromising the filling of both left atrium and left ventricle (see Fig. 1). Intravenous
Fig. 1. Color Doppler image demonstrating bidirectional flow within the pseudoaneurysm and partial compression of both left atria and left ventricle.
Letter to the Editor
153
presented at our heart-team meeting and at that time surgical repair of the Ps was decided. The surgical procedure was performed with extracorporeal circulation, consisting in resection of the Ps and closure of the ventricle rupture with a double-layer heterologous pericardial patch (see Online supplemental video). The postoperative period was unremarkable and the patient was discharged 10 days after the surgery. A control cMR confirmed the good result of the surgery, with partial resolution of the Ps and good state of the pericardial patch. Conflict of interest The authors report no relationships that could be construed as a conflict of interest. Supplementary data to this article can be found online at http://dx. doi.org/10.1016/j.ijcard.2015.06.129. References
Fig. 2. Balanced Turbo Field Echo (B-TFE) sequence showing the development of a huge left ventricular pseudoaneurysm near the infero-lateral wall of the left ventricle.
diuretic treatment was started and the patient was admitted to the Cardiology Ward. A new cMR showed the evolution of the Ps that was now about 118 × 99 × 84 mm (see Fig. 2). The case was again
[1] R. Moreno, E. Gordillo, J. Zamorano, C. Almeria, J.C. Garcia-Rubira, A. Fernandez-Ortiz, C. Macaya, Long term outcome of patients with postinfarction left ventricular pseudoaneurysm, Heart 89 (2003) 1144–1146. [2] E. Mujanovic, J. Bergsland, S. Avdic, S. Stanimirovic-Mujanovic, T. KovacevicPreradovic, E. Kabil, Surgical treatment of left ventricular pseudoaneurysm, Med. Arh. 68 (2014) 215–217. [3] F.A. Atik, J.L. Navia, P.R. Vega, G.V. Gonzalez-Stawinski, J.M. Alster, A.M. Gillinov, L.G. Svensson, B.G. Pettersson, B.W. Lytle, E.H. Blackstone, Surgical treatment of postinfarction left ventricular pseudoaneurysm, Ann. Thorac. Surg. 83 (2007) 526–531.
Contents lists available at ScienceDirect
International Journal of Cardiology journal homepage: www.elsevier.com/locate/ijcard
Letter to the Editor
Current role of cardiac imaging to guide surgical correction of a giant left ventricular pseudoaneurysm☆ Marcos Garcia-Guimaraes a,⁎, Carlos Velasco-Garcia-de-Sierra b, Francisco Estevez-Cid b, Lucia Perez-Cebey a, Alberto Bouzas-Mosquera a, Elizabet Mendez-Eirin a, Laura Fernandez-Arias b, J.J. Cuenca-Castillo b, J.M. Vazquez-Rodriguez a a b
The Cardiology Department of Complejo Hospitalario Universitario de A Coruña, Spain The Cardiac Surgery Department of Complejo Hospitalario Universitario de A Coruña, Spain
a r t i c l e
i n f o
Article history: Received 25 June 2015 Accepted 27 June 2015 Available online 2 July 2015
Pseudoaneurysm (Ps) is a rare complication after myocardial infarction (MI), even less frequent nowadays in the reperfusion era. Despite that MI is the most frequent cause of this condition, the presence of Ps has been described in the context of other conditions, such as mitral valve replacement, trauma or tumor invasion [1]. The Ps develops when a zone of cardiac rupture is surrounded by the pericardium, associated with an inflammatory and pro-thrombotic process that prevents progression to rupture and cardiac tamponade [2]. Previously the progression of these Ps to rupture in a great percentage of patients, leading to the classical indication of surgical correction, has been described [3]. Non-invasive cardiac imaging constitutes the cornerstone for the diagnosis of this condition, as well as gives valuable information to the cardiac surgery team to guide surgical correction. Here we present a clinical case of a 56 year-old gentleman with a previous history of hypertension and smoking, who was admitted to our institution for an acute episode of chest pain followed by syncope. On admission the patient was still symptomatic and hypotensive (systolic blood pressure of 80 mm Hg). The electrocardiogram showed an image of infero-lateral ST segment elevation myocardial infarction (STEMI). The patient underwent emergent coronary angiogram, which disclosed a 95% stenosis on the second acute marginal branch. The lesion was treated by the implantation of a bare metal stent. As the patient remained hypotensive after the procedure, he was admitted to our Coronary Care Unit. A transthoracic echocardiogram (TTE) revealed severe pericardial effusion and signs of cardiac tamponade. Then, an urgent pericardiocentesis was performed, draining 500 ml of ☆ Disclosures: none. ⁎ Corresponding author at: Complejo Hospitalario Universitario de A Coruña, As Xubias 84, 15006 A Coruña, Spain. E-mail address: [email protected] (M. Garcia-Guimaraes).
http://dx.doi.org/10.1016/j.ijcard.2015.06.129 0167-5273/© 2015 Elsevier Ireland Ltd. All rights reserved.
hemorrhagic effusion. The patient rapidly improved and a new TTE showed no significant pericardial effusion. With the suspicious of a mechanical complication after STEMI, a cardiac magnetic resonance (cMR) was performed, confirming the presence of cardiac rupture located in the infero-lateral wall of the left ventricle evolving to a small Ps. The case was discussed at the heart-team meeting and, as the patient remained stable for days, surgery was initially declined. Our patient was subsequently discharged and referred to be followed-up in our outpatient clinic. Unfortunately, the patient was lost to follow-up as he failed to attend the scheduled appointment. Eight months after the index admission, the patient returned to the emergency department of our institution, due to the acute onset of shortness of breath. On physical examination, the patient showed clear signs of pulmonary congestion. An urgent TTE confirmed the presence of a giant Ps, located on the infero-lateral wall of the left ventricle, with bidirectional flow within and compromising the filling of both left atrium and left ventricle (see Fig. 1). Intravenous
Fig. 1. Color Doppler image demonstrating bidirectional flow within the pseudoaneurysm and partial compression of both left atria and left ventricle.
Letter to the Editor
153
presented at our heart-team meeting and at that time surgical repair of the Ps was decided. The surgical procedure was performed with extracorporeal circulation, consisting in resection of the Ps and closure of the ventricle rupture with a double-layer heterologous pericardial patch (see Online supplemental video). The postoperative period was unremarkable and the patient was discharged 10 days after the surgery. A control cMR confirmed the good result of the surgery, with partial resolution of the Ps and good state of the pericardial patch. Conflict of interest The authors report no relationships that could be construed as a conflict of interest. Supplementary data to this article can be found online at http://dx. doi.org/10.1016/j.ijcard.2015.06.129. References
Fig. 2. Balanced Turbo Field Echo (B-TFE) sequence showing the development of a huge left ventricular pseudoaneurysm near the infero-lateral wall of the left ventricle.
diuretic treatment was started and the patient was admitted to the Cardiology Ward. A new cMR showed the evolution of the Ps that was now about 118 × 99 × 84 mm (see Fig. 2). The case was again
[1] R. Moreno, E. Gordillo, J. Zamorano, C. Almeria, J.C. Garcia-Rubira, A. Fernandez-Ortiz, C. Macaya, Long term outcome of patients with postinfarction left ventricular pseudoaneurysm, Heart 89 (2003) 1144–1146. [2] E. Mujanovic, J. Bergsland, S. Avdic, S. Stanimirovic-Mujanovic, T. KovacevicPreradovic, E. Kabil, Surgical treatment of left ventricular pseudoaneurysm, Med. Arh. 68 (2014) 215–217. [3] F.A. Atik, J.L. Navia, P.R. Vega, G.V. Gonzalez-Stawinski, J.M. Alster, A.M. Gillinov, L.G. Svensson, B.G. Pettersson, B.W. Lytle, E.H. Blackstone, Surgical treatment of postinfarction left ventricular pseudoaneurysm, Ann. Thorac. Surg. 83 (2007) 526–531.
