Case
A 28-years-old woman presented with symptoms evocating pulmonary
embolism. Thoracic computed tomography angiography disproved it but
showed a pseudoaneurysm of the left ventricle. We only noted a prior
ablation of accessory pathway for Wolff-Parkinson-White syndrome by
retrograde transaortic approach, 12 years
ago 6.
The pseudoaneurysm was 46 millimeters in diameter and partially
thrombosed. Its orifice was 12 millimeters in diameter and localized on
the lateral face of the left ventricle near the mitral annulus
(Figure 1). There was no mitral regurgitation and left ventricular
function was preserved. The calcified wall of the pseudoaneurysm was
close to the circumflex artery which was posteriorly repressed
(Figure 1). There was no extrinsic stenosis of the circumflex artery and
the rest of the coronary network was strictly normal. Because this
pseudoaneurysm was symptomatic and the risk of rupture was high,
intervention was indicated.
By sternotomy and left atriotomy approach, we exposed the mitral valve
and found the orifice behind P1 (Figure 2a). We detached the posterior
mitral valve from the anterior commissure to the median portion of P2
(Figure 2b). We closed the orifice by suturing a round piece of Dacron
patch (HEMASHIELDTM – Maquet, Germany). We first
placed a crown of pledgeted #4-0 polypropylene U-stitches passed from
the inside of the pseudoaneurysm to the ventricular bank around the
orifice (Figure 2c). The circular patch of 3 centimeters in diameter,
covering almost 1 centimeter around the orifice, was then attached
(Figure 2d). Suture was reinforced around with some #5-0 polypropylene
stitches. Finally, we reattached the posterior mitral valve by a run
suture like a sliding valve repair (Figure 2e). Time of clamp was
105 minutes. Intraoperative transesophageal echocardiography confirmed
the disappearance of any communication between the left ventricle and
the pseudoaneurysm, without mitral regurgitation. Computed tomography
before discharged confirmed the sealing of our repair with total
thrombosis of the pseudoaneurysm. The patient discharged from hospital
at postoperative day 9. Computed tomography at month 3 and month 15
confirmed the persistence of the sealing (Figure 3). Thereafter,
clinical and echocardiographic follow-up was done, stopping irradiation
in this young woman. Finally, no events such as recirculation of the
pseudoaneurysm, stroke, myocardial infarction, mitral regurgitation or
death during follow-up was reported until postoperative month 48.