Transthoracic echocardiographic imaging in diagnosis of post-operative left ventricular pseudoaneurysm


Aurora Cardiovascular Services, Aurora Sinai/Aurora St. Luke's Medical Centers, Aurora Medical Group, Cardiovascular and Thoracic Surgery


A 29-year-old male presented with 7 days of fever and chest pain. His medical history was significant for rheumatic heart disease post-mechanical mitral and aortic replacement 6 years prior. Three months ago, the patient developed extensive atrial, valvular, and ventricular thrombus caused by non-compliance to warfarin; he subsequently underwent emergent redo double valve replacement with a 21 mm CarboMedics mechanical aortic valve replacement and a 27 mm mechanical mitral valve replacement (CarboMedics Inc., Austin, TX, USA) and left ventricular (LV) apical thrombus evacuation. A transthoracic echocardiogram was performed on this admission, demonstrating normal functioning mechanical valve replacements but also a pericardial effusion (Panels A and B; see Supplementary dataonline, Videos S1 and S2) and an apical LV pseudoaneurysm with associated large apical pericardial haematoma (Panel C; see Supplementary data online, Video S3). The patient was taken emergently to the operating room, and a large pseudoaneurysm was found at the LV apex with significant amount of necrotic tissue and purulent fluid (Panel D). Thorough debridement and careful repair of LV were performed. Despite the successful surgery, the patient developed multi-organ failure and expired in the hospital. Late post-operative LV pseudoaneurysm is a rare post-operative complication. Our patient had redo median sternotomy and redo double valve replacement surgery; at the time of that operation, the LV apex was debrided of thrombus but was noted to have poor tissue quality, with difficulty of holding sutures, and was torn, requiring suture repair. In our patient, transthoracic echocardiogram provided clear diagnosis of his critical condition despite the presence of repeat sternotomy and two mechanical valves.

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