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Table of Contents
Year : 2012  |  Volume : 15  |  Issue : 3  |  Page : 247-249
Left ventricular pseudoaneurysm following mitral valve surgery

Department of Anaesthesia and Perioperative Medicine, Monash Medical Centre, Clayton, Australia

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Date of Web Publication4-Jul-2012

How to cite this article:
Manikappa S, Ingram B. Left ventricular pseudoaneurysm following mitral valve surgery. Ann Card Anaesth 2012;15:247-9

How to cite this URL:
Manikappa S, Ingram B. Left ventricular pseudoaneurysm following mitral valve surgery. Ann Card Anaesth [serial online] 2012 [cited 2022 Jul 2];15:247-9. Available from:

A 56-year-old gentleman presented with increasing shortness of breath on exertion, orthopnea and paroxysmal nocturnal dyspnea. His past cardiac history included an open mitral valvotomy in 1970, an aortic valve replacement (St Jude Mechanical) in 1984 for endocarditis and a mitral balloon valvuloplasty in 2006. Preoperative transthoracic echocardiography revealed moderate mitral stenosis based on a planimetry valve area of 1.4 cm 2 and a mean transmitral gradient of 7 mmHg. There was doming of the anterior mitral leaflet and the posterior leaflet was immobile. His prebypass transesophageal echocardiography (TEE) revealed thickened, calcified and restricted anterior and posterior mitral valve leaflets. Mitral valve area was assessed as 1.0 cm 2 . There was marked enlargement of the left and right atrium, with subechoic contrast seen in the left atrium. Tricuspid valve annulus was dilated with severe tricuspid regurgitation. The aortic prosthesis was functioning normally with a satisfactory aortic gradient. The aortic root and the ascending aorta were mildly dilated, but there was no aortic regurgitation. There was mild right ventricular (RV) dilatation and dysfunction. Left ventricular (LV) function and size were normal. He underwent a mitral valve replacement with a 31-mm St Jude Mechanical valve and tricuspid valve repair with a 32-mm annuloplasty ring. Post cardiopulmonary bypass (CPB), TEE imaging revealed stable seating of the mechanical mitral prosthesis with a satisfactory gradient. There was no significant mitral regurgitation or paravalvular leak. The tricuspid regurgitation was trivial. His early postoperative course was complicated by a low cardiac output state requiring inotropic support and a coagulopathy requiring transfusion of blood products. He had a prolonged postoperative stay in the intensive care unit (ICU), further complicated by renal failure, for which he was commenced on hemodialysis.

TEE on the third postoperative day revealed a stable mechanical mitral prosthesis with satisfactory function, aortic prosthesis function unchanged, normal LV function, mildly reduced RV function and mild tricuspid regurgitation. Echogenic material was noted behind the RV without any evidence of chamber compression. His recovery was slow and he was extubated 2 weeks after his initial surgery. He remained in the ICU where, at 3 weeks post surgery, he had an asystolic cardiac arrest requiring cardiopulmonary resuscitation. Emergency re-sternotomy was performed in the ICU at which time significant pericardial hematoma was found, which had been causing tamponade. Circulation was re-established but a TEE imaging revealed a LV pseudoaneurysm (LVPA). The patient was grossly hemodynamically unstable, and it was decided that his clinical condition did not allow repair of the LVPA at this time. There had been no reaccumulation of pericardial blood. Serial echocardiograms over the next 2 weeks demonstrated an increase in the size of the cavity, with flow persisting from the LV into the lumen of the cavity. The patient's cardiovascular system stabilized over this period and surgical exploration was eventually performed.

The intraoperative TEE findings were consistent with previous scans. [Figure 1] and [Figure 2], [Video 1] Pre-CPB NQ30, Video 2 Pre-CPB NQ60 demonstrate the presence of a cavity, which, on color Doppler, appears to communicate with the LV inferior to the mitral valve prosthesis. The surgical procedure accessed the left atrium via the right atrium and interatrial septum. The prosthetic mitral valve was in situ and stable. The surgeon could not visualize the LV communication to the LVPA with the valve in situ; therefore, the mitral valve was then explanted for better exposure. The area was thoroughly inspected and no communication could be found. Suspecting it was a small defect related to the previous mitral valve repair, a bovine pericardial patch was placed on to the LV and the left atrium in the vicinity of the lesion as identified on the TEE. [Figure 3], [Video 3] Post-CPB NQ60 shows the absence of the communication from LV to LVPA. There was mild global LV dysfunction and RV dysfunction. The patient failed initial attempts at weaning from CPB despite inotropic support and subsequently required an intraaortic balloon pump (IABP). Following this, he was successfully weaned from bypass and returned to the ICU. Unfortunately, his condition progressively deteriorated over a long period and the patient died 2 months later.
Figure 1: Midesophageal two-chamber color flow Doppler view showing left ventricular pseudoaneurysm neck and cavity during systole

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Figure 2: Midesophageal two-chamber color flow Doppler view showing left ventricular pseudoaneurysm neck and cavity during diastole

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Figure 3: Midesophageal two-chamber color flow Doppler view after repair of defect

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LVPA is a rare complication of mitral valve replacement with an increased risk of rupture and consequently high mortality. [1] This occurs as a result of cardiac wall rupture that is then contained by the overlying fibrosis and pericardial adhesions. [2],[3] A communication to the ventricular cavity persists. [2] The other causes of LVPA are trauma, infection or myocardial infarction. Common locations are the inferior and posterior walls. [2] It is possible that in our case the LVPA may have resulted from disruption of the heart following chest compressions carried out during cardiopulmonary resuscitation rather than due to the surgery itself, but this possibility is extremely rare.

The diameter of the orifice of the neck is smaller than the diameter of the cavity of LVPA, and allows surgical closure. If untreated, it may result in complete rupture, arrhythmias, thromboembolism and congestive heart failure. [2] However, Sakai et al.[4] in their series of eight patients with LVPA following mitral valve surgery treated seven of them medically without any complications. They opined that when the LVPA is small and the communicating neck of the LVPA is very narrow, conservative management of a patient with LVPA may be possible. True aneurysms contain some myocardial elements in its walls and the diameters of the orifice and cavity may be equal. [5] This is most often managed medically. [2] Surgical repair for true aneurysm is indicated only when there is associated congestive heart failure, refractory arrhythmias, refractory angina or systemic embolization.

Clinical features of LVPA include chest pain, heart failure and systolic and diastolic murmur. Patients can be asymptomatic during the postoperative period. Hence, clinical features are nonspecific and unreliable. TEE is semi-invasive but extremely accurate due to the high-resolution images gained because of the proximity of the heart and mitral valve apparatus to the TEE probe. However, mechanical prostheses are strong reflectors and can produce shadowing and reverberations, making visualization of deeper structure difficult.

LVPA produce a bounded echo-free space with the orifice of a narrow neck communicating with the LV. [5] LVPA with a narrow neck produce lumen collapse during systole and expansion during diastole in contrast to larger necks that collapse during diastole and expand during systole. [6] A retrospective analysis of the TEE images of this patient did show partial collapse during diastole and expansion during systole. Differential diagnosis includes a localised pericardial effusion or hematoma, pericardial cyst or a diverticulum. LV diverticulae are rare congenital anomalies consisting of localized protrusion of endocardium and myocardium from the free wall of the LV. [7] LVPA can be diagnosed by LV angiography, computed tomography or cardiac magnetic resonance imaging (MRI). Although cardiac MRI and computed tomography are noninvasive and accurate, it may not be the choice in an unstable patient. LV angiography is invasive and involves injection of contrast agent. These are not without significant risks such as anaphylaxis and renal impairment.

In summary, TEE is an excellent tool for the assessment of cardiac function and valvular abnormalities. It must be used as often as possible in an unstable patient. Color and spectral Doppler will help in the diagnosis of LVPA, as early recognition and treatment could be crucial in patient survival.

   References Top

1.Saghir S, Mazur W, Kereiakes D. Large mitral annular left ventricular pseudoaneurysm detected by cardiac magnetic resonance imaging. J Invasive Cardiol 2007;19:88-9.  Back to cited text no. 1
2.Konen E, Merchant N, Gutierrez C, Provost Y, Mickleborough L, Paul NS, et al. True versus false left ventricular aneurysm: differentiation with MR imaging--initial experience. Radiology 2005; 236:65-75.  Back to cited text no. 2
3.Ropers D, Achenbach S, Pfeiffer S. Left ventricular pseudoaneurysm following myocardial infarction. Heart 2004;90:555.  Back to cited text no. 3
4.Sakai K, Nakamura K, Ishizuka N, Nakagawa M, Hosoda S. Echocardiographic findings and clinical features of left ventricular pseudoaneurysm after mitral valve replacement. Am Heart J 1992;124:975-82.  Back to cited text no. 4
5.Sutherland GR, Smyllie JH, Roelandt JR. Advantages of colour flow imaging in the diagnosis of left ventricular pseudoaneurysm. Br Heart J 1989;61:59-64.  Back to cited text no. 5
6.Ghersin E, Kerner A, Gruberg L, Bar-El Y, Abadi S, Engel A. Left ventricular pseudoaneurysm or diverticulum: differential diagnosis and dynamic evaluation by catheter left ventriculography and ECG-gated multidetector CT. Br J Radiol 2007;80:e209-11.  Back to cited text no. 6
7.Yazici M, Demircan S, Durna K, Yasar E. Left Ventricular diverticulum in two adult patients. Int Heart J 2005;46:161-5.  Back to cited text no. 7

Correspondence Address:
Shashikanth Manikappa
Department of Anaesthesia and Perioperative Medicine, Casey Hospital, 62-70, Kangan Drive, Berwick, Melbourne, Victoria-3806
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/0971-9784.97984

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  [Figure 1], [Figure 2], [Figure 3]

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