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.