Discussion
Cardiac pseudoaneurysms are rare conditions. Rarely symptomatic, their prognosis remains poor with a risk of rupture or stroke of 40‑50% within the first year 1. Myocardial infarction is the main etiology but post-surgical or -interventional pseudoaneurysms are described 1–5. Surgical treatment is indicated with mortality of 20‑30% 1. Percutaneous closure is described but the submitral localization make the procedure complex, increasing the risk of embolization or mitral regurgitation7.
Several surgical techniques to treat cardiac pseudoaneurysms are described, depending on its localization and the quality of the perianeurysmal cardiac tissue 8,5,9. Submitral position, close to the circumflex artery, increased the risk of myocardial infarction or need of coronary bypass on the lateral wall 8,10. In addition, calcifications on the wall made the suture fragile in this high mechanical stress region, increasing the risk of tear in the left atrioventricular groove 5,8.
To minimize both theses complications, we decided on an inside exclusion rather than a resection 5,8. Inside exclusion by left atriotomy was first described by Antunes to treat congenital submitral aneurysm by transatrial approach, incising the floor of the atrium to access inside the aneurysm by its roof 11. In our case, the circumflex artery was posteriorly repressed between the left atrium and the pseudoaneurysm which were not in-contact, that made this way unsuitable 10. We decided on a transmitral approach to close the orifice from the inside of the left ventricle. Transmitral approach was first described for post-infarction pseudoaneurysm when the mitral valve was also replaced 12. In this young woman, we aimed to preserve the mitral valve and took great care on performing a partial detachment-reattachment of the posterior mitral valve. The detachment of the posterior valve, already described by Miura et al., gave access to the orifice just behind the annulus without being bothered by the subvalvular apparatus 5. We closed the orifice with a patch rather than a direct suture to avoid mitral regurgitation by subvalvular geometry distorsion 8. Pledgeted U-stitches were performed thick enough but taking care of not to injure the circumflex artery. Finally, although the left atriotomy approach could be performed by video‑assisted right minithoracotomy, the coronary risk led us to prefer a sternotomy.
Closure was efficient and total thrombosis was done and permanent without any short- and long-term major events. Unlike post-infarction pseudoaneurysms, traumatic ruptures seem to be well limited and surrounded by firmness myocardial tissue which might explain the durability of our sealing repair.