Asian Cardiovasc Thorac Ann 2006;14:328-330
© 2006 Asia Publishing EXchange Ltd
Repair of a Giant Left Ventricular Pseudoaneurysm in a Jehovah’s Witness
Elizabeth O’Flynn, MRCS,
Sanjay Purkayastha, MRCS,
Thanos Athanasiou, PhD,
Roberto Casula, FECTS
Department of Cardiothoracic Surgery St. Mary’s Hospital London, United Kingdom
For reprint information contact: Thanos Athanasiou, PhD, Tel: 44 207 886 1147, Fax: 44 207 886 1763, Email: tathan5253{at}aol.com, 70 St. Olaf’s Road, Fulham, London SW6 7DN, United Kingdom
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ABSTRACT
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We report the successful surgical management of a giant chronic left ventricular pseudoaneurysm that developed after an inferior myocardial infarction in a 71-year-old female Jehovah’s Witness. The case presented a highly risky challenge to the surgeon because of the faith’s stance of refusing blood transfusion.
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INTRODUCTION
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Left ventricular (LV) pseudoaneurysm is a recognized sequela of myocardial infarction. The natural history of and the treatment approach (conservative or surgical) for this lesion are issues of debate.1,2 If the patient is a Jehovah’s Witness (JW), the decision on management is further complicated by such followers’ refusal to accept transfusion of blood or blood products in accordance with their faith, thus significantly raising the surgical risk. Despite the higher risk, studies have shown that JW patients should not be excluded from redo operations, LV reduction, multiple valve replacement, or even implantation of ventricular assist devices, heart transplantation, or other complex aortic root procedures.3 We present here the successful surgical management of an elderly JW patient with a large LV pseudoaneurysm.
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CASE REPORT
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A 71-year-old lady of the JW faith, who had an inferior myocardial infarction in 2002, presented one year later primarily with lower esophageal dysphagia and more recently increasing shortness of breath on exertion (New York Heart Association class II). A 12-lead electrocardiogram demonstrated ST elevation and Q waves in leads II, III, and aVF. Ventricular arrhythmia was excluded by 24-hour Holter monitoring. Cardiac angiography revealed a proximally blocked right coronary artery, a non-significantly stenosed circumflex artery, and a large LV pseudoaneurysm not involving the posterior submitral apparatus. This observation was further delineated by magnetic resonance imaging, which showed that the left ventricle had ruptured inferiorly, resulting in a 10.9 x 8.1 x 10.4 cm giant aneurysm containing a thick layer of laminated thrombus (Figure 1
). The neck of the aneurysm was wide, measuring 5.2 x 5.7 cm, and communicated freely with the LV cavity. There was subendocardial infarction at the neck of the aneurysm, although the rest of the myocardium was functioning reasonably well with a LV ejection fraction of 52%. Transesophageal echocardiography showed mild mitral regurgitation. On the basis of the symptoms and the significant size of the aneurysm, surgical management was considered.
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Figure 1. Magnetic resonance imaging showing a giant inferobasal left ventricular pseudoaneurysm filled with laminated thrombus (arrow).
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Preoperative hematology revealed a hemoglobin concentration of 13.3 g·dL–1 and a hematocrit of 41%. Aspirin was discontinued a week before surgery. Pharmacological agents for blood conservation were discussed, including aprotinin, erythropoietin, and iron supplementation. Erythropoietin was not indicated preoperatively in view of the satisfactory hematocrit. Iron, however, was recommended to optimize iron stores so as to maximize the benefit from erythropoietin in case its use was warranted in the postoperative period, and the patient was commenced on ferrous sulfate 200 mg 3 times daily. In view of the presence of ischemic heart disease, the use of desmopressin was not considered. The potential use of recombinant activated factor VII was also discussed as part of the strategy in the event of massive hemorrhage. The recombinant product contains small amounts of human albumin, which was deemed acceptable by the patient. Although she refused blood transfusion, the patient consented to cardiopulmonary bypass (CPB) and the intraoperative use of a cell saver.
The aneurysm was repaired through a median sternotomy under normothermic CPB without aortic crossclamping. Gross adhesions were identified particularly around the inferolateral pericardium, which was carefully mobilized. With the patient placed in an extreme Trendelenburg position, the aneurysm was incised and the thrombus removed. Ventricular fibrillation was induced to facilitate repair, and the defect was covered with a glutaraldehyde-preserved bovine pericardial patch measuring 5.5 x 6 cm (Figure 2). The incised wall of the aneurysm was then plicated over the patch with polypropylene sutures and fibrin glue was inserted between these 2 layers. The right coronary artery area was not revascularized, as it had been obliterated by the LV rupture. Intraoperatively, transesophageal echocardiography confirmed that no significant mitral regurgitation was present. Aprotinin (3 million units) was administered. The recovered blood was not reinfused, as there was minimal blood loss. Total CPB time was 66 minutes and total operating time 205 minutes.
The following day, hemoglobin was found to be 9.0 g·dL–1 and hematocrit was 28%. They were 9.3 g·dL–1 and 25%, respectively, at discharge 5 days later. Ferrous sulfate was continued upon discharge. Transthoracic echocardiography performed before discharge confirmed a functioning left ventricle with an ejection fraction of 55%, end-diastolic volume of 102 mL, and end-systolic volume of 40 mL. Histological examination confirmed the diagnosis of pseudoaneurysm. At 1-month follow-up, the patient’s symptoms had improved significantly with the status of her shortness of breath elevated to New York Heart Association class I.
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DISCUSSION
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Mortality in JW patients undergoing cardiac surgery has decreased in recent years despite more elderly patients being operated on. This could be due to technological improvements, the use of new drugs in cardiac surgery, and increasing awareness of the risk factors associated with operative mortality. The leading cause of death reported in JW patients is still blood loss, however other important factors associated with early death have been identified as repeat cardiac operations, severe LV dysfunction, and hemoglobin levels below 8 g·dL–1 on postoperative day 1.5 A literature search on cardiac surgery in JW patients failed to elucidate a mortality rate for JW patients undergoing repair of LV pseudoaneurysm, however the figure for non-JW patients is approximately 10%. Ott and Cooley4 reported LV aneurysm repair with concomitant aortocoronary bypass in 3 JW patients, who all died.
There are recent reports of repair of LV aneurysm or pseudoaneurysm that emphasized avoidance of CPB and external plication of the aneurysm, or the use of left thoracotomy and the Heartport endovascular CPB system.6,7 Although these "less invasive" techniques can be helpful in reducing operative morbidity and mortality, in our case we considered using sternotomy and bicaval cannulation on CPB for two reasons. Firstly, the lesion was located inferiorly, which did not allow adequate access through a left thoracotomy. Secondly, the division of substantial amounts of adhesions can increase the operative risk significantly because of possible hemodynamic compromise and unexpected bleeding during dissection of the pseudoaneurysm. The patch technique is more often used on posterior aneurysms than on the anterior type, especially when the neck of the aneurysm is close to the mitral valve and valve distortion from direct closure is a potential risk.
In order to achieve a successful outcome when operating on a JW patient, besides awareness of the risk factors, systematic use of multiple blood conservation techniques can be considered that exploit appropriate combinations of drugs, surgical aids, and surgical or medical techniques. A multidisciplinary team approach is also required, involving physicians, surgeons, anesthetists, and other specialists, in managing an operation without the support of allogeneic blood transfusion.8
High-risk procedures can be offered to carefully selected JW patients if an individualized blood conservation protocol and surgical approach are applied. Experience obtained from this group of patients will be valuable in extending these techniques to non-JW patients, which will help surgeons towards achieving the goal of bloodless surgery.
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REFERENCES
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- Natarajan MK, Salerno TA, Burke B, Chiu B, Armstrong PW. Chronic false aneurysms of the left ventricle: management revisited. Can J Cardiol 1994;10:927–31.[Medline]
- Yeo TC, Malouf JF, Reeder GS, Oh JK. Clinical characteristics and outcome in postinfarction pseudoaneurysm. Am J Cardiol 1999;84:592–5.[Medline]
- McMullan DM, Beyer EA, Gregoric I, Radovancevic B, Frazier OH. Left ventricular reduction in a Jehovah’s Witness. Ann Thorac Surg 2000;70:958–61.[Abstract/Free Full Text]
- Ott DA, Cooley DA. Cardiovascular surgery in Jehovah’s Witnesses. Report of 542 operations without blood transfusion. JAMA 1977;238:1256–8.[Abstract/Free Full Text]
- Lewis CT, Murphy MC, Cooley DA. Risk factors for cardiac operations in adult Jehovah’s Witnesses. Ann Thorac Surg 1991;51:448–50.[Abstract]
- Sepic J, Aranki SF, Cohn LH. Minimally invasive Port-Access repair of a left ventricular pseudoaneurysm. J Thorac Cardiovasc Surg 2002;124:1242–3.[Free Full Text]
- Ono M, Wolf RK. Left ventricular pseudoaneurysm late after mitral valve replacement. Ann Thorac Surg 2002;73:1303–5.[Abstract/Free Full Text]
- Helm RE, Rosengart TK, Gomez M, Klemperer JD, DeBois WJ, Velasco F, et al. Comprehensive multimodality blood conservation: 100 consecutive CABG operations without transfusion. Ann Thorac Surg 1998;65:125–36.[Abstract/Free Full Text]
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ABSTRACT
INTRODUCTION
