Asian Cardiovasc Thorac Ann 1998;6:57-59
© 1998 Asia Publishing EXchange Pte Ltd
Femoral Bypass with Left Thoracotomy for Submitral Left Ventricular Aneurysm
Soman Rema Krishna Manohar, MCh,
Ramesh Chandra Rathod, MD1,
Jagan Mohan Tharakan, MD, DM2
Department of Cardiovascular & Thoracic Surgery
1 Department of Anaesthesiology
2 Department of Cardiology Sree Chitra Tirunal Institute for Medical Sciences & Technology Thiruvananthapuram, India
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For reprint information contact: Soman Rema Krishna Manohar, MCh Department of Cardiovascular & Thoracic Surgery Sree Chitra Tirunal Institute for Medical Sciences & Technology Thiruvananthapuram 695011, India Tel:91 471 44 3152 Fax:91 471 44 6433 or 55 0728 Email:sctimst{at}ren.nic.in
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ABSTRACT
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A simplified technique for repair of submitral left ventricular aneurysm is presented. Since the patient had no mitral regurgitation the aneurysm was approached through a left thoracotomy with femorofemoral bypass and the repair was technically simple.
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INTRODUCTION
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Submitral left ventricular aneurysms are rare. Although originally described in Africans, sporadic reports have since come from other countries and include Caucasian patients.1,2 These aneurysms are usually repaired through a median sternotomy either by a transatrial approach or directly.1–4
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CASE REPORT
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A 30-year-old female presented with a history of effort dyspnea (New York Heart Association functional class II) and palpitations of 3 years duration. Chest radiograph showed a large paracardiac shadow on the left side. Echocardiogram and angiogram revealed a large posterior submitral left ventricular aneurysm with no mitral regurgitation and normal coronary arteries (Figure 1
). In the supine position under general anesthesia the patient was heparinized and the right femoral artery and vein were exposed and cannulated. The patient was then repositioned in the right lateral decubitus position and a left posterolateral thoracotomy was performed through the 6th intercostal space. The aneurysm was exposed after opening the pericardium both anterior and posterior to the phrenic nerve and retracting the nerve.
Cardiopulmonary bypass was started and the patient was core-cooled. The heart was fibrillated and a left atrial vent was introduced through the body of the atrium. At 20°C nasal temperature, the patient was tilted head downwards, bypass flows were reduced to 0.5 L•min–1•m–2, and the aneurysmal sac was opened vertically. The left ventricular cavity was kept full and not aspirated. The mouth of the aneurysm measured 3 x 4 cm and it was irregularly oval and calcified. It was closed using a sandwich patch of plasma-preclotted Dacron and gluteraldehyde-tanned pericardium with Teflon pledgetted interrupted 3/0 polypropylene sutures (Figure 2). The aneurysmal sac was excised and the edges approximated using Teflon felt reinforced 3/0 polypropylene continuous suture (Figure 3).
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Figure 2. Technique of patch closure of the mouth of the submitral aneurysm after opening the aneurysmal sac vertically. Excellent visualization is achieved by this approach. Interrupted pledgetted 3/0 polypropylene sutures are used. AO = aorta, LA = left atrium, LV = left ventricle, PA = pulmonary artery.
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Figure 3. The repair completed by subtotal excision of the aneurysmal sac and closure using Teflon felt reinforced continuous 3/0 polypropylene suture. AO = aorta, LA = left atrium, LV = left ventricle, PA = pulmonary artery.
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The bypass flows were increased and the patient was re-warmed. At 26°C the heart was defibrillated to sinus rhythm and at 36°C the patient was weaned off bypass without any problems. In the immediate postoperative period the patient was re-explored for control of bleeding from the parietes. Apart from this, she made a good recovery. During the follow-up period she was asymptomatic and chest radiograph showed clearance of the paracardiac shadow. A left ventriculogram repeated 20 months after surgery showed no aneurysm and normal function (Figure 4).
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DISCUSSION
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Although rare, congenital submitral aneurysms of the left ventricle are usually large with a well defined neck beneath the posterior mitral annulus. The patients may present with hemodynamic impairment, mitral regurgitation, thromboembolism, or ventricular tachycardia.1–3 Such aneurysms may be approached through a median sternotomy and the repair is carried out through the floor of the left atrium (roof of the aneurysm), through the mitral valve, or directly through the aneurysm.1–5 The transatrial approach described by Antunes1 also gives exposure for concomittent mitral valve repair. Although a posterolateral thoracotomy gives the most direct access in these cases, institution of cardiopulmonary bypass is difficult due to the large pulsating aneurysm filling the operative field and preventing access to the great vessels. We therefore decided to use prior femorofemoral cannulation.
Dense pericardial adhesions do not make this approach difficult since all that is needed is to open into the collapsed aneurysmal sac. If the sac is multiloculated, the loculi can be divided to expose the ventricular communication. The repair is easy in a large calcified mouth such as in our case and also in cases presenting with multiple openings.5 Since the aneurysm is opened well away from the neck, there is no risk of injury to the circumflex coronary artery, which is easily visible and therefore protected.
Aneurysm resection is indicated in cases presenting with ventricular tachycardia.3 Subtotal excision aneurysmorraphy makes this technique useful for such cases. This also makes drainage of the aneurysmal sac unnecessary, which was suggested for preventing problems of dead space and recurrence.1 Any thrombus inside can be removed under direct vision and the left atrium and ventricle can be aspirated to remove residual air before defibrillating the heart.4 Because the aorta is not cross-clamped, the surgeon can take care of any unexpected situations satisfactorily without risk of myocardial ischemia. We therefore recommend that this simple direct technique should be used for repair of a submitral left ventricular aneurysm when a concomitant mitral valve procedure is not planned.
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REFERENCES
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Antunes MJ. Submitral left ventricular aneurysm correction by a new transatrial approach. J Thorac Cardiovasc Surg
1987;94:241–5.[Abstract]
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Esposito F, Renzulli A, Festa M, et al. Submitral left ventricular aneurysm. Report of 2 surgical cases. Texas Heart Inst J
1996;23:51–3.[Medline]
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Janeira LF, Talit U, Parker R, et al. Surgical management of ventricular tachycardia in subannular left ventricular aneurysm. Ann Thorac Surg
1995;60:438–40.[Abstract/Free Full Text]
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Gokhalae AGK, Lal N, Ashok B, et al. Mitral valve replacement for annular submitral aneurysm of left ventricle. Thorax
1993;48:676–7.[Abstract/Free Full Text]
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Korula A, Vaska K, Bakthavizhayam A, et al. Idiopathic annular subvalvular left ventricular aneurysm. Indian Heart J
1983;35:184–6.[Medline]
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ABSTRACT
INTRODUCTION
