Ann Thorac Surg 2002;73:1967-1969
© 2002 The Society of Thoracic Surgeons
Case report
Spontaneous disappearance of a false aneurysm after iatrogenic ruptured ventricle
Masayoshi Ito, MDa*,
Hirokazu Murayama, MDa,
Atsushi Ishida, MDa,
Souichi Asano, MDa,
Yasutsugu Nakagawa, MDa
a Department of Cardiovascular Surgery, Chiba Cardiovascular Center, Ichihara, Japan
Accepted for publication November 1, 2001.
* Address reprint requests to Dr Ito, Department of Thoracic and Cardiovascular Surgery, Sapporo Medical University School of Medicine, South 1, West 16, Chuo-ku, Sapporo 060-8543, Japan
e-mail: mlc33560{at}nifty.com
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Abstract
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We report the case of a 64-year-old woman who had an atypical subendocardial aneurysm, a space between the internal patch, which was used for the repair of a left ventricular rupture after mitral valve replacement, and myocardium, which filled with blood during the diastole phase. During the follow-up period, the aneurysm spontaneously disappeared. This case endorses combining internal and external approaches to repair a left ventricular rupture after mitral valve replacement.
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Introduction
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Left ventricular rupture is a known and often fatal complication of mitral valve replacement [1–6]. Different techniques for repairing a ventricular rupture have been described in accordance with the three different types [4]. The external and the internal repairs are two well-known techniques, and there is controversy concerning the relative merits and the drawbacks of each of them [1]. In this case report, we present the usefulness of a technique that combines internal and external repairs to repair a left ventricular rupture after mitral valve replacement.
A 64-year-old woman (height, 148 cm; weight, 40.8 kg) underwent mitral valve replacement for mitral stenosis with a 27-mm St. Jude Medical valve (St. Jude Medical, Inc, St. Paul, MN). The mitral leaflets were very thickened, with moderate calcification extending into the subvalvular apparatus. The leaflets were excised leaving about a 2-mm rim, preserving the basal chordae tendineae of the posterior leaflet. The operation went well, but as the sternotomy was being closed, brisk bleeding was noted to originate from the posterior pericardium, and the incision was reopened. Cardiopulmonary bypass was reinstituted, the aorta was cross-clamped, and the myocardium was arrested and cooled with a blood cardioplegic solution. The St. Jude Medical prosthesis was removed. Operative findings included a 1.5-cm longitudinal epicardial slit and a 4.5-cm transverse endocardial break, 3.5 cm and 2 cm inferior to the atrioventricular groove, respectively, in the posterior wall. A pericardial patch large enough to cover the defect and the injured myocardium around it was sutured to the healthy myocardium and partially to the mitral annulus with pledgeted sutures. In addition, the epicardial defect was repaired with Teflon-buttressed interrupted sutures. Fortunately, the epicardial tear was far enough from the posterolateral branch to repair (Fig 1).
The St. Jude Medical prosthesis was then secured to this pericardial patch and mitral annulus with multiple pledgeted-supported sutures. Cardiopulmonary bypass was again discontinued without difficulty.
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Fig 1. Repair of a left ventricular rupture. (A) Internal repair: a pericardial patch large enough to cover the defect and the injured myocardium around it was sutured to the healthy myocardium and partially to the mitral annulus with pledgeted sutures. (B) External repair: the epicardial defect was repaired with Teflon-buttressed interrupted sutures.
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The patient had an uncomplicated postoperative course. However, postoperative angiogram and echocardiogram performed at 4 weeks revealed an atypical subepicardial aneurysm, a space that was filled with blood during the diastolic phase between the internal patch, which was used for the repair of a left ventricular rupture after mitral valve replacement, and myocardium (Fig 2).
Because the patient had no symptoms such as ischemia, arrhythmia, or thrombosis, we decided to strictly monitor the patient. Two years after the operation, the echocardiogram and angiogram revealed spontaneous disappearance of the subepicardial aneurysm.
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Fig 2. Postoperative angiogram. (A) Diastolic phase: an atypical subepicardial aneurysm (arrows), a space filled with blood between the internal patch and myocardium. (B) Systolic phase: the atypical subepicardial aneurysm was not seen.
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Comment
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A left ventricular rupture after mitral valve replacement, although infrequent, may be a highly fatal complication, with a 0.5% to 2.0% incidence and a mortality rate of approximately 65% [2]. Three types of ruptures, etiologic factors, and techniques of repair have been described on the basis of their anatomic location [4].
With regard to the basic procedures for a successful repair, two approaches of the repair have been available [1]: the external and the internal repair. The external repair has been performed from the epicardial aspect of the heart by interrupted, pledgeted sutures, with or without patching [1]. This approach, while simple to perform, has a higher risk of rebleeding and false aneurysm formation, because the location and size of the endomyocardial and pericardial defects do not always correspond [5]. To solve these problems, Celemin and coworkers [6] subscribe to the removal of the prosthesis and advocate the insertion of an autologous internal pericardial patch large enough to cover the defect, the injured myocardium, and the neighboring left atrium. They also reported that it is most important to place every suture in healthy myocardium. However, it is not always possible to attain a secure approximation of the edges of the truly healthy myocardium because there might be transverse fiber disruption even at a rather long distance from the major tear [5]. According to Laplace’s law, although the internal patch is useful to exclude the injured myocardium including the tear without tension in the systolic phase, an increasing tension during the diastolic phase may disrupt the suture line, if the myocardium at the suture line is profoundly fragile. In our patient, the atypical subepicardial aneurysm observed during the diastolic phase developed due to the detachment of the internal patch because of the reason described above. However, under this condition, external repair prevented the tear and hematoma from spreading to the epicardial side, because the left ventricular pressure during the diastolic phase was low and the myocardium of the epicardial side was relatively strong to the longitudinal traction by its anatomical arrangement [5]. Fortunately, spontaneous disappearance was attained in our patient. Once the repair fails, an increasing degree of damage and extensive hematoma will make the repair more difficult [6]. Thus, we recommend a combination of internal and external repairs to reduce the disadvantages of each of them.
As for the atypical subendocardial aneurysm observed in our patient, there is no definite surgical indication. However, if aneurysm dilation or other symptoms associated with the aneurysm were recognized, surgical intervention should be performed. During the follow-up period, two-dimensional echocardiography and transesophageal echocardiography was useful for the noninvasive diagnosis and precise evaluation of the aneurysm.
In conclusion, we believe that a combination of internal and external repairs is useful to completely repair a left ventricular rupture after mitral valve replacement.
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References
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Karlson K.J., Ashraf M.M., Berger R.L. Rupture of the left ventricle following mitral valve replacement. Ann Thorac Surg 1988;46:590-597.[Abstract]
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Bjork V.O., Henze A., Rodriquez L. Left ventricular rupture as a complication of mitral valve replacement: surgical experience with eight cases and a review of the literature. J Thorac Cardiovasc Surg 1977;73:14-22.[Abstract]
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Katske G., Golding L.R., Tubbs R.R., et al. Posterior midventricular rupture after mitral valve replacement. Ann Thorac Surg 1979;27:130-137.[Abstract]
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Miller D.W., Johnson D.D., Ivey T.D. Does preservation of the posterior chordae tendiae enhance survival during mitral valve replacement ?. Ann Thorac Surg 1979;28:22-27.[Abstract]
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Cobbs B.W., Hatcher C.R., Craver J.M., et al. Transverse midventricular disruption after mitral valve replacement. Am Heart J 1980;99:33-50.[Medline]
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Celemin D., Nunez L., Gil-Aguado M., et al. Intraventricular patch repair of left ventricular rupture following mitral valve replacement: new technique. Ann Thorac Surg 1982;33:638-640.[Medline]
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Abstract
Introduction
