Left Ventricular Aneurysm Repair Through Left Thoracotomy Approach

<p>A 54-year-old man presented three months after coronary bypass surgery with a large aneurysm from the left ventricle (LV). Transesophageal echocardiogram (TEE) showed a wide-mouthed aneurysm arising from the lateral wall of the LV. LV ejection fraction was 35% and the patient’s mitral and aortic valves were competent. Computed tomography (CT) showed a 6 x 5 cm aneurysm with patent bypass grafts, the left internal mammary artery to diagonal, and venous grafts to the left anterior descending and posterior descending arteries. In view of the recent bypass surgery with the anticipated adhesions and patent bypass grafts, achieving adequate exposure for repair through a redo median sternotomy approach would have been difficult. Hence, the authors decided to operate through a left lateral thoracotomy approach.<br></p> <p>With the patient in the right lateral position, the left femoral vessels were cannulated. A left lateral thoracotomy was done, and the chest was entered through the fifth intercostal space. Hemorrhagic pleural fluid was sucked out. The adhesions between the heart and left lung were released. Cardiopulmonary bypass was established through the femoral cannulas. The heart was fibrillated after core cooling to 28°C. The aneurysm was then opened, and stay sutures were placed to expose the neck of the aneurysm. Braided 2-0 polyester sutures with pledgets were placed along the neck of the aneurysm in an interrupted mattress fashion. A collagen-coated woven polyester tube graft was cut appropriately and used as a patch for left ventricular reconstruction. The interrupted sutures were then passed through the patch margins. The patch was seated, and the sutures were tied. Deairing was done through the suture line before tying the last few sutures, and the heart was defibrillated.</p><p>The patient was weaned off cardiopulmonary bypass and protamine was given. After achieving hemostasis, the aneurysm wall was sutured over the patch. Postoperative TEE showed a well-restored LV with fair contractility, and a CT scan showed a perfectly contoured left ventricle with patent bypass grafts. With this technique, the authors were able to avoid redo sternotomy and its potential complications. All the bypass grafts were well protected, and a good exposure of the aneurysm was possible for a perfect repair.</p><p><strong>Suggested Reading</strong></p><ol><li>Frances C, Romero A, Grady D. Left ventricular pseudoaneurysm. <em><a href="https://www.ncbi.nlm.nih.gov/pubmed/9741493">J Am Coll Cardiol. 1998;32(3):557-561</a></em>.</li><li>Yakierevitch V, Vidne B, Melamed R, Levy MJ. False aneurysm of the left ventricle. Surgical treatment. <em><a href="https://www.ncbi.nlm.nih.gov/pubmed/703362">J Thorac Cardiovasc Surg. 1978;76(4):556-558</a></em>.</li><li>Akins CW. Resection of left ventricular aneurysm during hypothermic fibrillatory arrest without aortic occlusion. <em><a href="https://www.ncbi.nlm.nih.gov/pubmed/3485741">J Thorac Cardiovasc Surg. 1986;91(4):610-618</a></em>.</li><li>Shapira OM, Aldea GS, Carr TG Jr, Shemin RJ. Thoracotomy for repair of left ventricular aneurysm in a patient with patent coronary bypass grafts. <em><a href="https://www.ncbi.nlm.nih.gov/pubmed/7979693">Ann Thorac Surg. 1994;58(5):1536-1538</a></em>.</li></ol>

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