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An Extensive Calcified Left Ventricular Aneurysm: Case Report

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An Extensive Calcified Left Ventricular Aneurysm: Case Report OLGU SUNUMU An Extensive Calcified Left Ventricular Aneurysm: Case Report İhsan ALUR, a ABSTRACT A calcified left ventricular aneurysm (CLVA) is a rare, serious complication of acute Tevfik GÜNEŞ, a myocardial infarction. It can lead to angina pectoris, thromboembolism of ventricular origin, ven - a tricular arrhythmia, ventricular pseudoaneurysm or rupture, progressively enlarging aneurysms, Gökhan Yiğit TANRISEVER, congestive heart failure, and death. Treatment is surgical for symptomatic or asymptomatic LVAs a Bilgin EMRECAN larger than 5 cm, particularly when there is comorbid coronay artery disease. Its standard treatment is a ventriculoplasty and aneurysmectomy using the Dor technique. The aim of surgical treatment aDepartment of Cardiovascular Surgery, of an LVA is to reduce oxygen consumption in the LV by reducing end-diastolic volume (EDV), cre - Pamukkale University ating the ideal ventricle geometry, and preventing thrombus formation. The surgical results are Faculty of Medicine, Denizli often good. This article presents a patient with CLVA in whom we performed surgery. Ge liş Ta ri hi/ Re ce i ved: 12.02.2016 Key Words: Heart ventricles; heart aneurysm; thoracic surgery Ka bul Ta ri hi/ Ac cep ted: 04.04.2016 ÖZET Kalsifik sol ventrikül anevrizması (KSVA) akut miyokard infarktüsünün nadir ve ciddi bir Ya zış ma Ad re si/ Cor res pon den ce: komplikasyonudur. Bu komplikasyon anjina pektoris, ventriküler kaynaklı tromboemboli, ventri - İhsan ALUR küler aritmi, ventriküler psödoanevrizma veya rüptür, progresif genişleyen anevrizma ve konjestif Pamukkale University kalp yetersizliği gibi fatal kardiyak olaylara yol açabilir. Semptomatik veya asemptomatik, 5 cm’den Faculty of Medicine, büyük SVA’ların, özellikle eşlik eden koroner arter hastalığı da varsa tedavisi cerrahidir. Standart Department of Cardiovascular Surgery, tedavisi anevrizmektomi ve Dor tekniği ile yapılan ventriküloplastidir. Sol ventrikül anevrizma - Denizli, larında cerrahi tedavinin amacı, end-diyastolik hacmi (EDH) küçülterek sol ventrikülün oksijen TÜRKİYE/TURKEY tüketimini (talebini) azaltmak, ventrikülün ideal geometrisini oluşturmak ve trombüs oluşumunu [email protected] engellemektir. Cerrahi sonuçları çoğunlukla yüz güldürücüdür. Bu yazıda KSVA tanısıyla cerrahi uyguladığımız olgu sunuldu. Anahtar Kelimeler: Kalp ventrikülleri; kalp anevrizmasi; göğüs cerrahisi Turkiye Klinikleri J Cardiovasc Sci 2016;28(1):39-42 calcified left ventricular aneurysm (CLVA) is a mechanical compli - cation that develops after acute transmural necrosis of the my - ocardium. 1 It can lead to angina pectoris, thromboembolism of ventricular origin, ventricular arrhythmia, ventricular pseudoaneurysm or rupture, progressively enlarging aneurysms , congestive heart failure, and death. Its standard treatment is surgical. 1-4 The aim of surgical treatment of an left ventricular aneurysm (LVA) is to reduce oxygen consumption in the left ventricular ( LV) by reducing end-diastolic volume (EDV), creating the ideal ventricle geometry , and preventing thrombus formation. 1-4 The sur - doi: 10.5336/cardiosci.2016-50856 gical results are generally good. This article presents a patient with CLVA Cop yright © 2016 by Tür ki ye Kli nik le ri in whom we performed surgery. Turkiye Klinikleri J Cardiovasc Sci 2016;28(1) 39 İhsan ALUR ve ark. YAYGIN KALSİFİK SOL VENTRİKÜL ANEVRİZMASI CASE REPORT SURGICAL METHOD A 66- year -old man presented with shortness of A standard median sternotomy was performed breath. Three weeks earlier, he required car - under general anesthesia. A left internal mammary diopulmonary resuscitation (CPR) following car - artery (LIMA) graft was prepared. After opening diac arrest. On physical examination , his pulse rate the pericardium and suspending it, the patient was was 84 /min, he had a blood pressure of 90/60 heparinized. Arterial cannulation from the ascend - mmHg, and peripheral pulses were palpable. The ing aorta and two-stage venous cannulation from electrocardiogram showed sinus rhythm. Transtho - the right atrium were performed. After cannula - racic echocardiography showed dilated cardiomy - tion, cardiopulmonary bypass (CPB) was initiated opathy , severe LV systolic dysfunction, a large left at the appropriate activated clotting time . Using a atrium (52 mm) , and an ejection fraction (EF) of cross -clamp, cardiac arrest was induced via isother - 10- 15%. Cardiac magnetic resonance imaging in - mic hyperkalemic antegrade blood cardioplegia. A dicated that his LV was markedly enlarged (axial large calcified aneurysm was seen involving a large transverse diameter 87 mm), had severely reduced area of the LV apex (Figure 2A ). A ventriculotomy contraction, was hypofunctioning, and had re - was performed and sutured internally with a 4× 3 duced wall thickness at the apex; he also showed cm Dacron patch. Then the opened aneurysm was pronounced enlargement of the left atrium (Figure closed externally using the Dor procedure with 1A /1B ). On coronary angiography, the left anterior Teflon felt (Figure 2B , 2 C). 2 Subsequently, an descending artery (LAD) was narrow with 80% LIMA-LAD distal anastomosis was performed . The stenosis proximally, and pericardial calcification cross-clamp was removed, and the CPB was grad - was seen (Figure 1C ). Aneurysmectomy, ventricu - ually ended with inotropic support. The patient loplasty , and single-vessel coronary artery bypass was transferred to the intensive care unit and dis - grafting (CABG) were planned for the patient. In - charged without any problems on the seventh post - formed consent was obtained from the patient. operative day. FIGURE 1: A) MRI image (aneurysmal sac), B) CT image, C) Coronary angiogram (LAD proximal lesion and calcification line). FIGURE 2: A) Incision of aneurysm sac, B) Ventricular cavity, C) Endoventricular patch. Turkiye Klinikleri J Cardiovasc Sci 2016;28(1) 40 İhsan ALUR et al. AN EXTENSIVE CALCIFIED LEFT VENTRICULAR ANEURYSM: CASE REPORT Circular patch: A convenient method for the DISCUSSION back or bottom wall of an LVA . A thrombectomy During an LVA, the ventricular diameter increases is done by opening the aneurysm sac and resecting while the wall thickness decreases . Increasing wall it so that a 2 cm margin remains . The defect is tension increases both oxygen consumption and closed using a synthetic patch. 1,4 the demand on the previously infarcted ischemic Dor procedure (endoventricular patch tech- myocardium, causing ischemia in non-aneurysmal nique): The Dor procedure is a convenient method segments. In patients with an LVA, death of car - for treating aneurysms in the anterior wall of the LV. diac origin generally results from malignant ven - It gives good results when used for aneurysms larger tricular arrhythmias, congestive heart failure, or than 8 cm diameter. The aneurysm sac is opened; the recurrent acute myocardial infarction .1 Our patient wall is left where it is. A patch suitable for the nor - suffered a sudden cardiac arrest requiring CPR mal tissue border is prepared (generally from Teflon three weeks earlier . felt) and sutured continuously to the normal tissue There is no standard surgical treatment for a and aneurysm tissue border from the endocardial calcified LVA. It has been suggested that the results surface with a Prolene suture; then the native of surgery in patients who respond to medical treat - aneurysm sac is closed over the patch with a Prolene ment are worse than those of the medical treat - suture. The most important feature of an endoven - ment. 3 Nevertheless , the 5- year survival of LVA tricular circular patch-plasty is that it improves the with medical treatment is 8 -12%, and surgery in - function of the LV by preserving its geometry. The creases this to 75-90%. 2 Systemic embolization, re - main objective of the aneurysmectomy is to reduce 1,4,5 current arrhythmias, congestive heart failure , and the LVEDV and regional wall stress . The Dor pro - angina pectoris are all indications for surgical treat - cedure has some advantages compared to a linear re - ment. Methods used for the surgical treatment of an pair; it eliminates the septal akinetic areas and allows LVA include plication, linear suture repair, place - reorganization of the remaining viable myocardium ment of a circular patch, and the Dor procedure. 1,4 (like its positive effect on the remodeling of the LV muscle fibers, and causes no restrictions or bending). Plication: This is used for small , thrombus-free Finally, without narrowing the LV cavity, it allows aneurysms, which can be plicated from the outside complete resection of the aneurysm, including 1,4 without opening the aneurysm sac. subendocardial scar tissue. 5 Linear suture repair: The aneurysm sac is The surgical anterior ventricular restoration opened. If there is a thrombus, a thrombectomy is (SAVER) technique: This is a form of the Dor pro - performed . The aneurysm tissue is resected so that cedure. In this technique, the infarcted tissue in the a 3 cm rim remains. Supporting the defect from anterior wall of the LV is cut parallel to the LAD outside, a horizontal mattress suture technique is and the intraventricular space is examined. The live used and the two vertical surfaces are closed pri - and scarred myocardium tissue border is palpated marily with a continuous suture. The results are transmurally. This border is excluded from the often unsatisfactory because this technique causes ventricular cavity with an approximately 2- 3 cm LV distortion and leaves akinetic/dyskinetic areas sewing ring, using
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