A 65-year-old diabetic man presented to our hospital with chest pain and shortness of breath at rest and frequent awakening due to chest discomfort at night for about 10 days.
He revealed a history of anterior MI 1 month ago. Percutaneous coronary intervention (PCI) was performed at that time for the blocked left anterior descending artery with a drug eluting stent. Post-PCI echocardiography showed a normally functioning heart.
Physical examination indicated blood pressure of 140/85 mmHg, heart rate of 86 beats/min, and a continuous murmur at apical area. Electrocardiography (ECG) showed T-wave inversion in the infero-lateral leads. Chest X-ray displayed an oval bulge on the left border of the heart [Figure 1]. Transthoracic echocardiography showed a large oval anechoic area with a distinct thin wall at the lateral border of the LV, mild mitral regurgitation and good LV function. Coronary angiography showed normal flow in the left and right coronary arteries and the patent stent in left anterior descending.
The preoperative diagnosis was an aneurysm of LV. Hence, LV aneurysmoplasty was the planned surgery. The patient was premedicated with tablet ranitidine 150 mg and tablet etizolam 0.5 mg on the night and morning of surgery. Anesthesia was induced with injection midazolam 0.05 mg/kg, injection fentanyl 10 mcg/kg, injection etomidate 0.3 mg/kg, and injection vecuronium 0.2 mg/kg. Standard monitoring techniques and transesophageal echocardiography (TEE) were used. Intraoperative TEE showed a large (8.2 cm x 6.9 cm) oval out-pouching from the posterolateral aspect of LV, which was communicating with the LV chamber through a passage measuring 2.7 cm [Figures 2 and 3]. LV function was good but with hypokinesia in the lateral wall. The wall of the cystic cavity was akinetic. After going on cardiopulmonary bypass and administration of cardioplegia, the cystic wall adhering to the pericardial cavity was dissected and opened [Figure 4]. The wall of the cystic cavity did not show any myocardium. The redundant pseudoaneurysm was excised, and the defect on the LV wall was closed with pledgeted teflon. The durations of cardiopulmonary bypass and aortic cross clamp were 108 and 74 min respectively. Postbypass TEE showed hypokinesia of lateral wall of LV and good LV function.
The patient was discharged on the 7th postoperative day. At his 3 months follow-up, the patient was in New York Heart Association I status, echocardiography showed good LV function with an ejection fraction of 62%.