Year : 2013  |  Volume : 16  |  Issue : 3  |  Page : 209--211

Idiopathic left ventricular outflow tract pseudoaneurysm


Ajay Kumar Jha1, Rakesh Pandey1, Parag Gharde1, V Devagourou2, Usha Kiran3,  
1 Department of Cardiothoracic and Vascular Anesthesia, All India Institute of Medical Sciences, New Delhi, India
2 Department of Cardiothoracic and Vascular Surgery, All India Institute of Medical Sciences, New Delhi, India
3 New Delhi, India

Correspondence Address:
Ajay Kumar Jha
Department of Cardiothoracic and Vascular Anesthesia, All India Institute of Medical Sciences, Ansari Nagar, New Delhi - 110 029,
India

Abstract

Left ventricular outflow tract (LVOT) pseudoaneurysm is a rare occurrence and may produce clinically unpredictable symptoms. A very few cases of LVOT pseudoaneurysm are reported and there has always been a predisposing factor in these reported cases such as history of infective endocarditis, myocardial infarction, prosthetic aortic valve replacement or chest trauma. Our patient did not have the above predisposing conditions. Intra operative transesophageal echocardiography helped patient management and guided the surgical team in securing and isolation of the aneurysmal sac from the LVOT.



How to cite this article:
Jha AK, Pandey R, Gharde P, Devagourou V, Kiran U. Idiopathic left ventricular outflow tract pseudoaneurysm.Ann Card Anaesth 2013;16:209-211


How to cite this URL:
Jha AK, Pandey R, Gharde P, Devagourou V, Kiran U. Idiopathic left ventricular outflow tract pseudoaneurysm. Ann Card Anaesth [serial online] 2013 [cited 2020 Sep 27 ];16:209-211
Available from: http://www.annals.in/text.asp?2013/16/3/209/114252


Full Text

 Introduction



Left ventricular outflow tract (LVOT) pseudoaneurysm is an infrequent, clinically innocuous entity but with potentially life threatening consequences. Unlike aneurysm in which entire wall of either ventricle or aorta forms the wall of the sac, in the case of pseudoaneurysm wall is formed by thickened epicardial or pericardial layer. The LVOT pseudoaneurysm has been reported in patients having history of cardiac surgery, myocardial infarction, prosthetic aortic valve replacement, infective endocarditis, chest trauma and congenital heart diseases particularly outlet type of ventricular septal defect. [1],[2],[3],[4],[5],[6],[7] Mitral - aortic intervalvular fibrosa is predominantly fibrous, avascular, and is prone to infection and trauma which can lead to aneurysm formation. [8] The symptomatology is usually vague and is secondary to obstruction produced by the aneurysmal sac of the surrounding structures like LVOT, coronary arteries, pulmonary artery, left atrium, and left main bronchus or it may be fatal if it ruptures in these structures. [7] Although transesophageal echocardiography (TEE) is better in delineation of anatomy of aneurysmal sac; the transthoracic echocardiography (TTE) can help in initial diagnosis with precision. [1] Standard or modified parasternal long axis view is useful if neck lies below non-coronary cusp and apical five chamber view if neck lies below right coronary cusp. [9] Multi detector computed tomography (CT) angiography further helps in establishment of actual origin and spread of sac. [10],[11] The localization of neck is important for proper surgical planning and technique. Here, we present a case of LVOT pseudoaneurysm that was not preceded by any predisposing conditions described in the literature.

 Case Report



A 45-year-old, 55 kg male was referred to our institute with dyspnea of exertion modified medical research council questionnaire grade 2 and angina on exertion (Canadian cardiovascular society) grade 2 associated with profuse sweating since last 6 months. He was previously admitted in another hospital with symptoms of congestive heart failure 2 months back, which was then medically controlled and provisionally diagnosed as aortic dissection. He had no history of any comorbid illnesses or prior hospitalization. Chest X-ray showed cardiothoracic ratio of 0.7 with left border displacement and mild pleural effusion on left side. Electrocardiogram showed left ventricular strain pattern. Hemogram and renal function were within normal limits. TTE showed large sac surrounding aorta and left atrium. CT angiography was done which showed large multi-locular sac with a neck of 1.7 cm, arising from LVOT burrowing in antero-posterior plane into mediastinum. It was surrounding right pulmonary artery, left atrium, and left main bronchus extending up to right atrium - superior vena cava junction and also seen compressing left aortic sinus, left circumflex, and left anterior descending artery. Aortic annulus, aortic root, ascending aorta, and descending aorta, right ventricle and all the valves were normal. On cardiac catheterization no evidence of coronary artery diseases was found.

On the day of surgery, a large bore intravenous cannula and arterial line was secured prior to induction of anesthesia. Heart rate, blood pressure, central venous pressure, oxygen saturation, and temperature were within normal limits. Patient had normal sinus rhythm. Anesthesia was induced after pre-oxygenation, with etomidate 0.2 mg/Kg, fentanyl 3 μg/Kg and rocuronium 1 mg/Kg. After tracheal intubation with 8.5 mm endotracheal tube, TEE probe was inserted for evaluation and delineation of anatomy of the aneurysmal sac. Neck of the sac was found to arise below the right coronary cusp. Ascending aorta, and left atrium were encircled by the sac [Figure 1] and [Figure 2]. A large intra-septal hematoma was also seen. No pressure gradient was noted across the aortic valve and aortic regurgitation was absent. TEE helped in facilitating venous and the aortic cannulation. On surgical exposure aneurysm neck was found to be arising from right lateral aspect of LVOT below the junction of right and non-coronary sinuses. Opening of the sac was closed with interrupted pledgeted sutures. Bypass time was 81 min and cross-camp time was 41 min. Patient was weaned from cardiopulmonary bypass with dopamine 10 μg/Kg/min, adrenaline 0.1 μg/Kg/min, and noradrenaline 0.1 μg/Kg/min. After gradual weaning from inotropes and ensuring minimal mediastinal drain, trachea was extubated after 12 h. Rest of the post operative recovery of the patient was uneventful.{Figure 1}{Figure 2}

 Discussion



LVOT pseudoaneurysm is a rare clinical entity and its clinical features also are not predictable. Our patient presented with angina like symptoms but he did not have any risk factor associated with coronary artery disease. Literature search did not show any article mentioning LVOT pseudoaneurysm without any predisposing factor. Various case reports in literature have mentioned it after history of infective endocarditis, myocardial infarction, chest trauma, cardiac surgery, prosthetic aortic valve implantation, and following closure of outlet type ventricular septal defect. [1],[2],[3],[4],[5],[6],[7] Our patient did not have history of any of these associated causative factor. In our case even remote speculation of LVOT pseudoaneurysm was difficult and, therefore, a unique one. Echocardiography may not be always accurate in diagnosing LVOT aneurysm since several pathological entities produce echo free space around left atrium such as fluid in oblique pericardial sinus, cor-triatriatum, dissection of left atrial wall, and pericardial cyst. [12] Echocardiography may help differentiating pseudoaneurysm and aneurysm. In case of pseudoaneurysm, neck is always narrower than the main body while in case of aneurysm, the size of neck is as big as main body.

Anesthetic induction period is the most critical one in patients with LVOT pseudoaneurysm. Aneurysm rupture can occur, especially, if hypertensive response to laryngoscopy and intubation is not attenuated. In our case, coronaries were also compromised by the sac and hence we tried to maintain normal hemodynamics during induction and maintenance. Intra operative TEE helped in exact localization of aneurysm neck, which was secured and isolated from left ventricular outflow tract and finally we could see the disappearance of echo-free space [Figure 3].{Figure 3}

References

1Skoularigis J, Deviri E, Wisenbaugh T, Essop R, Middlemost S, Sareli P. Role of transesophageal echocardiography in diagnosis of subaortic aneurysm. Am J Cardiol 1992;69:1102-4.
2Daniel WG, Mügge A, Martin RP, Lindert O, Hausmann D, Nonnast-Daniel B. Improvement in the diagnosis of abscesses associated with endocarditis by transesophageal echocardiography. N Engl J Med 1991;324:795-800.
3Bhagwat AR, Patil RB, Loya YS, Sharma S. Sub aortic aneurysm in infective endocarditis. Am Heart J 1991;122:588-9.
4Matthews RV, French WJ, Criley JM. Chest trauma and subvalvular left ventricular aneurysms. Chest 1989;95:474-6.
5Gupta R, Jammula P, Huang MH, Atar S, Ahmad M. An unusual complication after aortic valve replacement. J Clin Ultrasound 2006;34:361-4.
6Hoffman JI. Congenital anomalies of the coronary vessels and the aortic root. In: Emmanouilides GC, Riemenschneider TA, Allen HD, Gutgesell HP, editors. Moss and Adams' Heart Disease in Infants, Children and Adolescents, 5 th ed. Baltimore: William and Wilkins; 1995. p. 784
7Yeo TC, Malouf JF, Reeder GS, Oh JK. Clinical characteristics and outcome in postinfarction pseudoaneurysm. Am J Cardiol 1999;84:592-5, A8.
8Chesler E, Korns ME, Porter GE, Reyes CN, Edwards JE. False aneurysm of the left ventricle secondary to bacterial endocarditis with perforation of the mitral-aortic invervalvular fibrosa. Circulation 1968;37:518-23.
9Mohan JC, Khan JA, Sethi KK, Arora R, Khalilullah M. Two-dimensional echocardiographic diagnosis of subaortic aneurysm. Indian Heart J 1993;45:61-3.
10DaCol U, Ramoni E, DiBella I, Ragni T. An unusual left ventricular outflow pseudoaneurysm: Usefulness of echocardiography and multi detector computed tomography for surgical repair. Cardiovasc Intervent Radiol 2009;32:188-91.
11TsaiI C, Hsieh SR, Chern MS, Huang HT, Chen MC, Tsai WL. Pseudoaneurysm in the left ventricular outflow tract after prosthetic aortic valve implantation: Evaluation upon multi detector-row computed tomography. Tex Heart Inst J 2009;36:428-32.
12Kluger R. Common diagnostic pitfalls and cardiac masses. In: Sidebotham D, Merry A, Legget M, editors. practical Perioperative Transoesophageal Echocardiography. London, England: Butterworth-Heinmann; 2003. p. 69-87.