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.