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Left ventricular aneurysm repair with pericardial patch,

Orchard Park, New York
Best answers
PRE-OP DIAGNOSIS: Acute myocardial infarction with rupture of the left ventricular free wall and mild mitral regurgitation

POST-OP DIAGNOSIS: Chronic pseudoaneurysm with rupture of left ventricular free wall and mild mitral regurgitation

PROCEDURE: Left ventricular aneurysm repair with pericardial patch, transesophageal echocardiography.

INDICATIONS: transferred here from Kenmore Mercy. I was called emergently to the Cath Lab by Dr. because of this patient's suspected acute myocardial infarction and rupture of his left ventricular free wall. Cardiac catheterization showed total occlusion of the circumflex coronary artery, it was dump occluded after the take of the obtuse marginal. He was diagnosed with pseudoaneurysms left ventricle and taken emergently to the operating room. In retrospect after surgery I believe his pseudoaneurysm is chronic in nature and due to the intraoperative findings.

PROCEDURE: The patient was taken to the OR and placed on the table supine position, monitored appropriately and prepped and draped in usual sterile manner. Transesophageal echocardiography was performed and revealed a large pseudoaneurysm in the posterior aspect of the left ventricle. It communicated freely with the left ventricle. There was a large hole. There was mild mitral regurgitation and aortic valve was competent, left ventricle was functioning in the anterior and inferior wall but was akinetic in the posterior wall.

The patient was cannulated via the left femoral vessels. He had an existing femoral venous line in and this was removed and the patient was systemically heparinized and cannulated via left femoral artery and left femoral vein in preparation for cardiopulmonary bypass.

A midline chest incision was made and carried down to the sternum. The sternum was split with a sternal saw it was thin, very narrow sternum and a bit thin on the right side therefore Robicsek weave was placed here prior to closure. Dissection was carried down to the pericardium, upon opening the pericardium there was found to be old organized blood anterior in the pericardium. I opened the pericardium and was able to strip this old blood off of the heart and perform further dissection inferiorly and posteriorly expecting to get into this pseudoaneurysm but this did not occur. In fact I was able to dissect the entire pseudoaneurysm without having to go on pump because of the chronicity of its nature. There was dense capsule around this pseudoaneurysm cavity and there were adhesions between this capsule and the pericardium, also adhesions between the heart and pericardium. I used blunt dissection with fingers and also sharp dissection with the Metzenbaum scissor to dissect out the pseudoaneurysm cavity. This was the first indication that this was more of a chronic situation.

Cardiopulmonary bypass was instituted and the patient was cooled to 30'C. A left ventricular vent was placed in the inferior pulmonary vein. The pseudoaneurysm capsule was then incised, filleted open the cavity and was able to visualize the defect in the left ventricle. It was a rather large defect extending up towards the base of the heart and measured 4 x 5 cm. Inspecting the defect revealed fibrotic material around the edges of the defect. There was no evidence of acute myocardial infarction or friable muscle, in fact the edges of the defect were quite scarred and fibrotic consistent with long-standing nature of this pseudoaneurysm.

I was happy to see this because it meant that the sutures would hold quite nicely and that patient's cardiac function was not acutely ill.

I felt that primary closure was not going to be possible as defect was too large and would result in two small left ventricular cavities therefore fashioned the pericardial patch to close the defect. This was sewn in with a running 4-0 Prolene suture and the suture line was buttressed with BioGlue. I then used the existing fibrotic capsule of the pseudoaneurysm to cover this pericardial patch. The pseudoaneurysm was about the size of a lemon and there was plenty of capsule tissue left to fold over the patch and this was sewn with a running 4-0 Prolene buttressed with a piece of felt and BioGlue applied on the outside. This was all done without cross clamp on cardiopulmonary bypass.

The patient is being rewarmed and attention was turned to wean from cardiopulmonary bypass. Weaning occurred successfully with a small dose of pressors. Protamine was then administered, cannulas removed from the femoral vessels and vein and artery were sewn up with a running 6-0 Prolene suture. The wound was irrigated with antibiotic solution and checked for hemostasis. Hemostasis was found to be excellent. Sump was placed anteriorly in the mediastinum and a Blake drain placed posteriorly in the area of the patch repair. The sternum was approximated with figure-of-eight binder cables, Robicsek weave was placed on the right side to reinforce this part of the sternum. The remainder of the wound was closed in layers of Vicryl. Skin closed with subcuticular Maxon. A sterile dressing was applied and the patient was taken to the Open Heart Unit in critical condition. He tolerated the procedure well.


True Blue
Richardson, TX
Best answers
Take a look at 33548.

"Physician performs a surgical ventricular restoration to treat CHF subsequent to MI that has caused scarring or aneurysm of the left ventricle. Rather than closing the defect, the physician sutures a patch over the defect to restore normal spherical shape of the heart"