In this video we review a challenging case of a 48-year-old woman presenting with chest pain. We explore the role of Echo, CT, and MRI imaging, and highlight how surprising and dramatic results led to a diagnosis of a Left Ventricular Pseudoaneurysm (LVPA). Using excellent intraoperative surgical video, we also explore the best surgical approach to treating LVPA. Topics include:
The diagnosis and possible etiologies of LVPA
Critical role of imaging for diagnosis and for planning surgical management
The keys to re-operating after previous, unsuccessful surgery to fix LVPA
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Hi, I'm doctor Randy Martin and I'm actually a clinical professor of cardiovascular surgery at Mount Sinai. I'm thrilled to be joined by one of my colleagues, uh who is a real surgeon. I, I'm, I'm a cardiologist but who uh Percy Bott Percy is actually the national director of the, it says here, Percy, the Mitral valve repair Reference center, which is good, but you're also associate professor of surgery and a fabulous surgeon. We had a chance to, to visit about a very interesting case. I think you're gonna really like this. So tell me a little bit about this case. I thank you Andy for that introduction. Um, this is a case of a lady who showed up, uh with uh chest pain and the pseudoaneurysm, uh which we repaired and thought everything was good. Um, she subsequently came back to us about 12, 8 months after the first repair with a recurrence. And I think it's a interesting case that illustrates a few points about surgery and, um, how we think through things and how we assess patients. All right, give me, give me a little bit more of her history because she didn't come in with a sign on her chest and said pseudoaneurysm. But, so tell me a little bit about it. So, uh, she's a 48 year old female who, um, had, had a very protracted hospital course about a year and a half before she showed up, uh, for, uh, venous thrombosis. Um, so she came in with chest pain and shortness of breath of about a week. Um, and as normal people, well, as usually happens in the, er, they get a bunch of studies immediately. Uh The first idea they got was um AC T A of the chest, um, an echocardiogram and, and they got an MRI all showing that she had a left a ventricular out pouch and which was called a pseudo both by the CT A and by the MRI. Ok. So they, they, they established the diagnosis but she came in with chest pain and shortness of breath, which is really look historically, one of the main ways that people with pseudoaneurysms present. Absolutely. Um I mean, when people come up with chest pain, of course, you go through the whole algorithm of whether it's coronary disease. Is it a pulmonary embolism? Is it some myocarditis? Any of those things could be the reason for presentation is that the pneumonia. Uh, but she got an echo which basically showed um, a focal out pouch of the left ventricle wall. They raised the question of a pseudoaneurysm ejection fracture was near normal. 51% normal ventricle cavity. No var regurgitation. So, the suggestion was to get an MRI to confirm. Um, so you've got, uh, I, I've done, you know, being an echocardiographer, I'm dying to see the, the image you've got, but the imaging is really important here and, and tell me a little bit more because you're, you're really getting into what the ideology of pseudoaneurysm. Absolutely. And, um, one of the, the good things about medicine today, unlike many years ago, when you go to the, er, somebody's already established either preliminary diagnosis and you have to, you know, either confirm or exclude that. Um So we were already told she had a pseudo, when we saw her in the emergency room as uh the cardio surgery team. Um, we went through the whole history of, you know, trauma, whether she had a history of myocardial infarction. Um And then we found out that she had, had a history of pericarditis uh with pericardial effusions. And at some point I had a pericardiocentesis and um excluding trauma, excluding history of infection, the history of myocardial infarction. We pretty much assumed that maybe the aneurysm was caused by this pericardiocentesis. Interesting because, because really, uh post M I is really most common. Uh, and, but, but trauma is also a common thing that can you show me a little bit about what, what actually, what you were seeing when you started at, at our studies. So this is a acorn presentation and you being an echocardiographer, I'll, I'll let you sort of know. I mean, it's, it's classic if you look in the, in the, in the lateral wall and most of the pseudoaneurysms are inferior laterally, aren't they posterior laterally? There, you see the classic out pouching, uh and classic marking of a pseudoaneurysm, small neck, a big, big uh cavity with pretty good, pretty good LV function. Uh And then she had, uh of course, all the imaging that we do in the emergency room. This was the uh the CT A that was done uh which uh confirmed uh the pseudo is right there. You see it over here, right? Yeah, I just run through it again. So, so she's got a pretty confirmed, you know, the differential. Um it, it certainly whenever you see something you're thinking about a true aneurysm pseudoaneurysm or a diverticulum, which is really a muscular outpouching of the V most often at the apex. But that, I mean, I'm sure you guys went through all these differentials. Absolutely. So, did you go ahead and get an MRI to get, I mean, they'd gotten an MRI to get further confirmation. Absolutely. And that one, I just learned his historical information. She had an echocardiogram in 2019, which is completely normal. So we knew that this was not something she had from birth, that exclusion. And it was, that was before the her pericardiocentesis. That was exactly before that. So that So she had a normal echo at that point in time. So go show me the MRI if you've got that because MRI shown uh again this narrow neck and a pouch in here which shows the pseudoaneurysm. Yeah. So, so Percy, what are you, what are you telling her? And what are you gonna do? Because these things are, when you find these, you gotta do something because their risk of rupture is pretty substantial. Absolutely. So we told her that, you know, with aneurysms of the ventricle wall, there's a couple of things you can do. One is medical management. Uh But one's the symptomatic, especially if the pseudo aurm, the risk of rupture is quite high and could be as high as 50% in the next few days to weeks. And if it ruptures, the mortality is also quite high. Uh So we needed to do a sort of an urgent operation to um take care of this and remove uh the source of the problem. So you're gonna show me so, but you looked at her corna first to make sure because that's obviously high on the hit list of ideology. Exactly. Uh We still have that in the back of our minds warning whether she may have had a silent myocardial infarction and she didn't know about. So to confirm that we got a, a further invasion of the coronaries and here you see, uh coronary angiogram showing the left vle um a shot of the, of the left system. Um, and you see, there's no coronary disease. Very clean vessels. We could. Yeah. Yeah, we'd all like to have coronaries that look like that. I think I would. But that's, uh, no, I mean, they're perfectly good. So now you've got, you're pretty, you feel confident that this is a pseudoaneurysm something you need to approach. So you're gonna, you've got, I know you've got some great or shots, but show me a little bit about what you did. Yeah. So we took it to the operating room and um did you know, standard cannulation? And here in this picture, you see us uh showing that the, the var uh wall. Um and we basically did that, you know, uh vent andros exclusion. Uh We did transvenous sutras uh and then put the patch thing through this just for a second. So, so for those of us that are not surgeons in the daily thing. So you went through the ventricle and then you put a patch in what, what you said, a a bovine pericardial patch in. So here the sus as you can see are going through the vicar wall and coming out through the neck of the aneurysm. And we're walking down and looking at the ventricle and these things are some of the Trabi or the left ventricle. So this is the neck of the aneurysm. He got it. OK. Um And these are the Sus heavy pearl and sus coming through the ventricle wall. Um So then we basically pass the sus through the patch and tie the patch down to the, that was what it looked like when you were through repairing it. And then once we tied the patch in, we closed here, here, here you see all the switches coming out and then, and then let me pause this for a second. That's fine. I mean, yeah. So these are the place of the sutures going through the wall through which the patches attached to the sus on the inside. And this is a ventricle oom me where we enter the pseudoaneurysm. Um And then we're gonna run this in a linear fashion to make the double patch, well, double layer closure, uh just a single patch, double layer closure. So you in the next shot, you see um the finished product of the linear closure. So, so the pseudoaneurysms are, are character, I mean, they're true ruptures of the wall and contained by usually by the pericardium or structure like that. So you're gonna close her. Absolutely. And then, uh and, and how did she do? Well, she did really well after this operation. Um No symptoms. Let me play this to the end. Um She was discharged from, this is the, the hard recovering against her, the very full repair. Um So, so she does well and this is her echocardiogram on discharge. So she looks good. She looks good. Uh LV function looks good. You can see your repair site there. Exactly. And I'm, I'm one of the principles of IOS repair again is to make sure you have a sizable LV cavity. When you're done, you don't want to exclude too much of a normal LV and make it a small and create diastolic dysfunction. So I think we achieved that. It looks, it looks good, looks good and everything looks good. But there's more to the story, right? So this is a discharge echo. One month she had to follow up echo. Um, looks perfectly fine. No risk current. He have some above, you know, about what she had 55% or higher. Looks great. Ok. So then we get a call from the, er, about eight months later that she's back in the, er, with chest pain and um we're all thinking, oh hopefully this is nothing that we did but it turns out she had imaging that showed a recurrence of the pseudoaneurysm. Let me see. Let me see what you see because you had, yeah, that's pretty dramatic. Yes. So this is a chest X ray. The first thing she got this time which shows, you know, obliteration of the lateral wall of the LV. So I just know that there's something else attached to the heart besides the heart. Um And then of course, as they normally get in the ear, they get every study you can think about which is, you know, good. She had another CT A uh which shows a very impressive um new pseudoaneurysm or recurrent pseudo. Um and uh as a surgeon that was quite disheartening to see, I was gonna say, I mean, everything going. Yeah. And we're laughing, not at the situation, but just at, at life in general. You never think so. Here you see this large cavity in the small neck there. So now, now you've got this woman's got two ventricles, it looks like, you know, to the novice here. So that's a and the true ventricle is here and this is a huge c under his cavity with a narrow neck here. So, so at that point, you sort of, um, sulk a little bit and kick your heels and say you gotta do something again. And as we know in surgery, reoperations are never fun, especially I can imagine that. So do I was this, is this more complicated because you're going through a lot of tissue and stuff. Absolutely. Is this, every time you have re operation is a little more dangerous, there's a lot of scar tissue. Um And technically, it makes for a harder dissection because we know the large cavity outside the heart is and make for a very challenging reoperation. So, so, so you take her back to the or you're gonna show me some, look, look at that. That's incredible. I mean, that's, you know, it's amazing to me that, uh, that she didn't have a more significant event. I mean, you know, that's basically a contained rupture. That's sizable. Exactly. And, um, yeah, you're right. I mean, she could have had embolic events, you know, and, and frankly, no, I mean, you've got smoke in the, in the pseudoaneurysm cavity and she, yeah, it's just, I mean, but a frank rupture, look at that. That's incredible. Yeah. Unreliable. So, we take it to the operating room, uh, which is, was quite challenging to dissect the heart of because any time you try to move the heart, it was attached to the lateral wall and it was very difficult to move. So we had to actually go and bypass early to be able to complete the dissection and free up the heart and all this uh pseudo cavity. And here you see it showing again a very narrow neck uh with a trabecula going across it. So that's the Rebeca and this is a very narrow neck with a large purism cavity. Where is the patch? Um That, that's the famous question. Exactly. So we looked around and we didn't really see a patch. So I'll take this back there. So just basically everything that the hiss we had the hiss and um the patch, this describe a remnants of the patch and these are the sutures that we put through. So I only guess is the patch disintegrated somehow. Uh the sutures probably ripped through, uh which is quite unusual because um the bull vampire Cardiac patch, which is the first time has been used for years and years for ventricular reconstruction for aneurysms and anything else. And this is probably the first time I've ever heard of this happening. And this must have been a gradual thing. I mean, you would think that obviously the size of the ca cavity makes you think it was gradual, but you think if it suddenly ruptured, she'd have an intense pain and, and, you know, maybe collapse. But this, so she came, she comes in with recurrent chest pain. So what are you gonna do this time? Well, um you say you, you say you're not a surgeon but you claim the surgeon's uh uh and as they go to one, so we decided we need to repat it. But this time went to choose something that was inert, completely inert, which is not use the bovine per cardio Megan and use a different patch technique. So, in this video, when I played the video, you see that we chose a Hema shield which is basically cloth, woven cloth. Uh We didn't think this would disintegrate. This is not biologic material. Um And then we changed our patch technique this time, we did a double patch closure with the Hema shield as opposed to an over closure with the Sudan Sudan cavity. So basically, you reinforce, reinforce it. And um uh uh the thing we do differently this time, we actually run the suture around the, the neck of the a, as you can see, as opposed to interrupt the sutures you by doing that. You think you had, you were thinking better stability, I mean, better enforcement, better strength, basically, more hemostatic, more hemostatic. Yeah. So this is the second patch on the outside and actually we end up resecting all of this, um, tissue, ok. And cut it off and left it off the heart. Um, so, so she did well after surgery, um went home with no problems and then, um, so she's doing very well. We checked on her a few weeks ago and she's doing quite well. No problem. She got an echocardio in about 12 months which showed the ejection fraction is normal, normal size and no recurrence. This is there. Look at that. That's absolutely amazing. Yeah. So, so percy, this is pseudoaneurysms are not common. They're, they're pretty uncommon. Again, the ideologies that you went through was post M I, they're almost always posterior and, and inferior posterior, lateral and inferior trauma. Uh I've seen some of, I've seen a couple after uh mitral valve replacement and the posterior mitral annuls and stuff. The, the idea here is to do a primary repair. I mean, did, did anybody ever say, gee maybe we should do a transcatheter approach since I've seen that attempted to? No, actually, you, you're right. I mean, it's reported in the literature and the people, you know, talk about doing transcatheter closures of these aneurysms, but given the age, given the location, uh, we thought it was a better approach to do the surgery, um, and they do a definitive repair and not take any chances with her. So it's something for the audience. It's something of the viewers to think that you, these are, are not common, but you certainly think about them as a differential of chest pain and shortness of breath in people. And your work worked him up noninvasively found things and, and the lessons you learned from. What if, if, if another one of these rolls in this afternoon, what, how are you gonna, you, are you gonna use the himi approach again or are you gonna, what are you gonna do 100%? I mean, it, it, it sounds sort of, um, you know, they, if you read the literature and, you know, people have done a repairs with both my bur and for years and years and years and never had this problem. Uh, I did look, look around to see if there's any reports of this problem. And actually I didn't really find anything. I, I found a paper from, uh, the Boston children's where they did using photo fix, which is, uh, another type of bone Vardi but that, that calcified and that became Aysal and there's only in two patients that have threated and something patients they did. So it's a very uncommon problem. It's a very unusual problem. Uh, but, you know, it needs but, but it needs, I mean, I'm thinking medical therapy would be, I mean, the risk of rupture of these is gigantic. Again, tell, tell us, tell me the differential is a true aneurysm is a is, is you have all layers, it pouching, this is a rupture of the myocardial. Absolutely. Yeah. So yeah, I mean, when, when these patients show up, you, you gotta be thinking in the congenital, acquired um acquired will be, you know, like trauma, trauma, M I infection. Uh some inflammatory disorders would do this. Um, so we went through all of this with her and she didn't have any of those. So, uh, unfortunately, we think that the, the, the inciting event was probably the perfect trauma. Yeah. Well, it's, it's a fascinating, I mean, fabulous case for the, for us to learn from and, and fabulous for you. You know, that she's, um, she's done extremely well, very complicated surgery and uh she needs great surgeons like you and others to do this. So I would say though that if, if I was to do this again with Bovine pericardium just I happen to be placed with no, you know, um, hey Michel, I would just double the patch, just do a, a sandwich to do the same thing, but with the bovine per and then double it, I use just one sheet of it and, and yeah, I mean, that's, that's a great lesson learned. And thanks for sharing this with me and with the audience, it's a fascinating case. Thanks for joining us.
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