Left ventricular aneurysmectomy in patients with poor left ventricular function.

Physical performance and left ventricular (LV) function in the resting state were assessed in 22 patients with postinfarction anterior-apical left ventricular aneurysm (LVA) and global ejection fraction less than or equal to 20% who subsequently underwent radical LVA resection. The basic findings in the 20 survivors of surgery were significant improvement of global systolic LV function and more or less complete recovery of regional ejection fraction in the predominantly viable low and high lateral LV wall. This improvement was evident in patients with concomitant bypass grafting as well as in those with isolated and ungraftable lesions of the left anterior descending (LAD) coronary artery. We conclude that postinfarction anterior-apical LVA in a poorly functioning LV is suitable for surgical treatment, which can be accomplished with acceptable risk. All graftable stenotic major coronary arteries should be bypassed, in addition to the LVA resection, but a minority of patients with isolated, ungraftable LAD disease are likely to benefit from aneurysmectomy alone.     

Off-pump excision of left atrial appendage aneurysm: a case report

Isolated congenital intrapericardial aneurysm of the left atrium (LA) or the left atrial appendage (LAA) is a rare anomaly [Zhao 1999]. The patient usually presents with features of systemic embolization, serious arrhythmia, and severe congestive cardiac failure as a complication, which can be fatal. Once the condition is diagnosed, surgery is indicated [Zhao 1999]. We report a case of congenital left atrial appendage aneurysm in a woman who underwent excision of the same.     

Subepicardial left ventricular aneurysm with an intraventricular narrow neck on the avascular apical area: Report of a case

A 48-year-old hiatus hernia patient with a history of an occasional epigastric burning sensation for the last 10 years presented with a new onset of chest pain in addition to the persistence of his other symptoms. An apical left ventricular aneurism was found on 64-slice computed tomographic angiography. Coronary angiography confirmed the diagnosis. No coronary lesion was found and the apical region of the left ventricle was avascular. He was operated on under the suspected preoperative possible diagnoses of left ventricular apical aneurysm, a pseudoaneurysm, or a diverticulum. Macroscopically, a subepicardial whitish aneurysmal region with a weakened wall was seen at the apical part of the left ventricle. The size of the lesion was 3 x 3 cm. The aneurysm did not have an extracardiac neck. When the aneurysm site was opened, a sclerotic aneurysm wall and a narrow neck below the incised sac was found; and the neck was communicating with the left ventricular cavity. The aneurysm site was resected and closed with a linear closure technique by using pledget-supported sutures. The termination of cardiopulmonary bypass was uneventful. The patient left the intensive care unit on the first postoperative day and was discharged from hospital on the 4th postoperative day. A subepicardial left ventricular aneurysm should therefore also be considered in the differential diagnosis of atypical chest pain.     

兔慢性室壁瘤模型的建立

目的 建立一种兔慢性左心室室壁瘤(LVA)模型.方法 取成年新西兰大白兔35只,结扎冠状动脉前降支和回旋支中段,造成急性心肌梗死(AMI).结扎前、结扎后当时和1个月后经心尖部测左心室内收缩末压(LVESP)和舒张末压(LVEDP).结扎前和1周及1个月后行超声心动图检查,测量左心室前后径(D1)、长径(D2)、室间隔厚度(IVS)、左室后壁厚度(LVPw)、左室舒张末容积(LVEDV)和收缩末期容积(LVESV)、射血分数(LVEF),计算室壁瘤所占左心室面积比例.留心脏标本做大体病理检查,用琼脂做左心室腔内铸型.结果 动物存活率88.6%,LVA模型成功率83.9%.超声心动图见心尖部和左室前侧壁膨出,运动消失或呈反常运动,LVA面积(33.4±2.4)%.形成LVA后,D2、IVS、LVEDV和LVESV显著增加,LVEF显著降低,D1和LVPW有增加趋势,但差异无统计学意义(P＞0.05).结扎冠脉后LVESP显著性降低,1个月后有回升,但仍显著低于正常.LVEDP进行性升高.病理检查室壁瘤累及左室心尖部和前侧壁,室间隔未受累.左心室腔内铸型见室壁瘤形成后心尖部和前侧壁明显膨出.结论 同时结扎冠脉前降支和回旋支中段,可形成面积较恒定的解剖性LVA,累及左室心尖部和前侧壁,不累及室间隔.腔内铸型法可用于研究左心室腔内立体构型.     

Paced latissimus dorsi used for dynamic cardiomyoplasty of left ventricular aneurysms

Two patients are described, each with a large left ventricular aneurysm and severe coronary artery disease, and each with an ejection fraction lower than 30% and in congestive heart failure. In both, the left latissimus dorsi (LD) muscle was used in the repair of the ventricular aneurysm because preoperative studies demonstrated that there was concomitant coronary artery disease, and there was a strong suggestion that resection of the entire aneurysm would seriously compromise the residual ventricular capacity. One patient had an 18-year history of coronary occlusion with two infarctions. A large, calcified ventricular aneurysm developed, and despite vigorous medical treatment, intractable congestive heart failure and angina persisted. The diffuse coronary artery disease made this patient a poor candidate for bypass grafting. The other patient sustained an acute myocardial infarction 5 months prior to operation. The left anterior descending coronary artery was totally occluded, and a large apical aneurysm developed along with an akinetic anterior wall and septum. After his heart attack, the patient had progressive dyspnea on exertion. Following operation in both patients, the transpositioned LD, then a component in the repair of the left ventricular wall, was electrically trained to synchronously contract with each systole, driven by a standard dual-chamber cardiac pacemaker. Steady improvement and a return to normal activities were observed in both patients. There was an indication of improved ejection fraction with synchronous contraction of the skeletal muscle.     

Multiple mycotic arterial aneurysms involving the left anterior descending coronary artery following mitral and aortic valve endocarditis: A case report

We present a 57-year-old man with recent Streptococcus viridans endocarditis on mitral and aortic valves who had a mycotic aneurysm of the left anterior descending (LAD) coronary artery and associated superior mesenteric and cerebral artery aneurysms. The patient had preoperative renal failure and the infection was controlled with ceftriaxone. Mitral and aortic valve replacement were performed using tissue valves and the LAD aortic aneurysm was ligated and the patient had saphenous venous graft to the LAD. The postoperative course was complicated by pleural effusion and the patient had antibiotic therapy for 6 weeks postoperatively.     

Spontaneous coronary artery dissection with left ventricular aneurysm--a case report of successful surgical repair

Spontaneous coronary artery dissection is a rare entity. To our knowledge, 86 cases have been reported, and there are 7 operative treatment. The patient was 56 year-old male with a history of the previous myocardial infarction. A selective coronary angiography demonstrated marked dilatation of both coronary arteries. The thin radiolucent lines were shown within the LAD and first diagonal branch as a result of partial separation of the intima. A very large left ventricular myocardial aneurysm was also demonstrated within anteroapical walls, he underwent open heart surgery with left ventricular myocardial aneurysmectomy and aorto-first diagonal branch saphenous vein graft. This present case is the second report which describe a successful surgical treatment for the spontaneous coronary artery dissection with left ventricular aneurysm.     

Surgical treatment of coronary aneurysm after percutaneous coronary intervention

A 61-year-old man with acute myocardial infarction underwent percutaneous coronary intervention with stent for the left main coronary artery (LMT) and the left anterior descending artery (LAD). Three months later, we recognized the LMT aneurysm complicated with possible thrombus formation, which developed in size during 6 months. In addition, the LAD stent showed significant in-stent stenosis. For the purpose of supplying blood flow to the distal of LAD, and avoiding myocardial infarction due to distal thrombosis possibly originated from LMT aneurysm, we decided to perform surgical operation. On preoperative examination, this patient had an obstruction of the right internal carotid artery. Although the direct repair of LMT aneurysm requires conventional approach with cardiopulmonary bypass, we applied off-pump coronary artery bypass grafting( OPCAB) considering the risk of cerebrovascular event. Consequently, OPCAB was performed in usual fashion [right internal thoracic artery (RITA) -LAD, left internal thoracic artery-left circumflex artery (LITA-LCX)] followed by the ligation of the proximal of LAD and LCX without cardiopulmonary bypass. The patient had a good operative course.     

Giant left atrial intrapericardial aneurysm: noninvasive preoperative imaging

Congenital giant intrapericardial aneurysms of the left atrium are rare. A 17-year-old boy presented with paroxysmal episodes of palpitations, chest pain, and dyspnea. A chest roentgenogram showed an enlarged left cardiac silhouette. Transthoracic echocardiography imaging showed an intrapericardial aneurysm of the left atrium. Cardiac magnetic resonance imaging confirmed the diagnosis and delineated adjacent structures to plan the surgical resection. We have found no previous reports of cases of diagnosis and preoperative assessment based solely on noninvasive imaging.     

Distribution of myocardial blood flow after left coronary occlusion

Myocardial blood flow (MBF) in eight anatomically similar canine left ventricles was determined by injection of radioactive microspheres during baseline conditions and immediately after sequential occlusion of the left anterior descending (LAD) and circumflex coronary arteries (LCF). The left ventricle was divided into: posterior, lateral, anterior, and septal zones, apex and base, and endocardial epicardial layers for mapping of left ventricular MBF by gamma counting. Areas with significant flow reduction showed a reversal of the ENDO/EPI ratio to <1 from the normal ratio of 1.2–1.3. After LAD occlusion the anterior wall received more collateral flow from the LCF than did the posterior wall from the LAD after LCF occlusion. After occlusion of LCF, MBF to the posterior wall and the basal portion of the lateral wall were most severely reduced; after the occlusion of LAD only the apical portion of the anterior wall showed marked MBF reduction. The interventricular septum received considerable heterogenous flow when either the LCF or LAD was occluded.     

Clinical significance of anterior mitral leaflet fibrillation in patients with nonvalvular atrial fibrillation: comparison with blood flow and wall motion of the left atrial appendage

Background and purpose  Diastolic fibrillation of the anterior mitral leaflet (AML) is seen in patients with atrial fibrillation (AF). However, its clinical significance has been unclear. On the other hand, reduced blood flow velocity in the left atrial appendage (LAA) may be associated with LA thrombus formation. In this study, we investigate the relationship between the flow velocity and the wall motion velocity of the LAA and diastolic fibrillation of the AML in patients with nonvalvular AF. Methods  We performed transthoracic echocardiography (TTE) in 45 consecutive patients with chronic nonvalvular AF. The LAA flow velocity was measured by pulsed Doppler echocardiography with the sample volume positioned at the center of the LAA. The LAA wall motion velocity was measured by pulsed Doppler tissue imaging (DTI) with the sample volume at the medial wall of the LAA. The AML fibrillation velocity was measured by pulsed DTI with the sample volume at the AML tip. Results  The AML fibrillation velocity could be measured in 44 patients (97.8%), and the LAA flow and wall motion velocities were measurable in 35 (77.8%) and 42 (93.3%) patients, respectively. The AML fibrillation velocity had a range from 4 to 21 cm/s and showed significant positive correlation with the LAA flow velocity (r = 0.82, P < 0.001) and the wall motion velocity (r = 0.80, P < 0.001) of the LAA. An AML fibrillation velocity of ≤7 cm/s predicted patients having a tendency to LA thrombus formation (LAA flow velocity ≤20 cm/s) with high sensitivity (87.5%) and specificity (88.9%). Conclusion  The AML fibrillation velocity seems to be a viable substitute for the LAA flow velocity in the detection of flow stagnation in the LA.     

Congenital Aneurysm of Left Atrial Appendage: A Case Report

Abstract   Aneurysm of the left atrial appendage (LAA) is a very infrequent condition. We report a case of a two-year-old child with congenital aneurysm of the LAA with a large thrombus in it. He presented with an episode of seizures with left-sided hemiparesis. Diagnosis was based on transthoracic echocardiography and magnetic resonance imaging. The patient was successfully treated by surgical resection of the aneurysm and removal of the thrombus. (J Card Surg 2010;25:37-40)     

Surgical repair of a congenital left ventricular aneurysm

Congenital left ventricular aneurysm is an uncommon cardiac malformation. A 9-year-old boy with complaints of dyspnea and palpitation was diagnosed with a left ventricular aneurysm originating from the left ventricle free wall. Aneurysm resection and endoventricular patch repair was performed. Postoperative follow-up was uncomplicated and follow-up echocardiographs showed normal left ventricular contractility.     

Superior mesenteric artery mycotic aneurysm in patients with left ventricular assist device support and intravenous drug abuse

Mycotic aneurysm of the superior mesenteric artery (SMA) is one of the complications associated with infective endocarditis. However, there are no previous case reports in the literature describing mycotic SMA aneurysm after left ventricular assist device (LVAD) implantation. We describe the case of a 31-year-old male diagnosed with congestive heart failure due to nonischemic dilated cardiomyopathy who underwent LVAD implantation for bridge to heart transplantation. The postoperative course was uneventful, and the patient was maintained on anticoagulation and antiplatelet therapy. There were no signs of pump failure or device-related infections. However, 7 months post-LVAD support, the patient complained of abdominal symptoms (nausea and vomiting) with low-grade fever. Computed tomography identified an aneurysmal change of the SMA (2.2 × 1.8 cm). There was no evidence of thrombus or septic vegetation inside the heart. Aneurysm and segmental small bowel resection was performed. Pathological study revealed typical findings of mycotic aneurysm with significant infiltration of inflammatory cells. The patient, however, expired due to concurrent brain hemorrhage. Postmortem study indicated no sign of pump thrombus or septic emboli inside the pump or inflow/outflow conduit. This case report presents a rare mycotic aneurysm that developed in the SMA after chronic LVAD support.     

Rare malposition of a central venous catheter into the left internal mammary vein in a liver transplantation patient

We report a rare malposition of a central venous catheter in a liver transplantation patient which occurred during an intensive care period. The waveform of central venous pressure was aberrant after connecting the catheter to the pressure kit transducer. It was misplaced into left internal mammary vein confirmed by thoracic computed tomography. Significant engorgement of the left internal mammary vein may have been the cause of this rare malposition.     

血硒对维持性血液透析患者左心室结构与功能的影响

目的探讨血硒对维持性血液透析(maintenance hemodialysis,MHD)患者左心室结构和功能的影响及其可能机制。方法运用质谱法、放射免疫法、化学发光法和生化比色法分别对40例MHD患者、40例非透析慢性肾衰竭(non-hemodialysis,NOHD)患者和30例正常对照者的血硒、甲状腺激素(thyroid hormone,TH)、甲状旁腺激素(parathyroid hormone,PTH)、氧化应激指标进行测定;应用Philips CX50彩色B超测定左心室内径(left ventricular diameter,LVD)、左心房内径(left atrial diameter,LAD)、左心室舒张末内径(left ventricular end-diastolic diameter,LVDd)、左心室后壁厚度(left ventricular posterior wall thickness,LVPWT)、室间隔厚度(interventricular septum thickness,IVST)、左心室射血分数(left ventricular ejection fraction,LVEF),按Devereux公式计算左心室质量指数(left ventricular mass index,LVMI)。分析血硒与其他参数的关系及其对左心室结构和功能的影响。结果MHD患者血硒、总三碘甲状腺原氨酸(total triiodothyronine,TT 3)、游离T 3(free triiodothyronine,FT 3)含量均低于正常对照组(P<0.01),PTH含量高于正常对照组(P<0.01),超氧化物歧化酶(superoxide dismutase,SOD)、谷胱甘肽过氧化物酶(glutathione peroxidase,GSH-Px)活性低于正常对照组(P<0.01),丙二醛(malondialdehyde,MDA)含量高于正常对照组(P<0.01),C反应蛋白(C-reactive protein,CRP)含量高于正常对照组(P<0.01),LAD、LVDd和LVMI均高于正常对照组(P<0.01)。MHD患者血硒与GSH-Px、SOD、TT 3、FT 3呈正相关(P<0.05),与CRP、MDA、LAD、LVDd呈负相关(P<0.05);GSH-Px与LAD、LVDd、IVST、LVMI呈负相关(P<0.05),SOD与LAD、IVST、LVMI呈负相关(P<0.05),MDA与LAD、LVDd、IVST、LVMI呈正相关(P<0.05);TT 3、FT 3与LAD、LVDd、IVST、LVMI呈负相关(P<0.05);PTH与LAD、LVDd、IVST、LVMI呈正相关(均P<0.01);CRP与LAD、LVDd、IVST、LVMI呈正相关(P<0.05)。结论低硒可能通过引起机体抗氧化能力降低、TH和PTH代谢紊乱、炎症反应增强,而加重MHD患者左心室结构和功能异常。     

Giant left ventricular pseudo-false aneurysm following myocardial infarction

We report a successful surgical ease of giant left ventricular pseudo-false aneurysm in a 63-year-old man. The abnormality of the inferior wall of the left ventricle was discovered incidentally by abdominal ultrasonography for health examination at another hospital. Transthoracic echocardiography and left ventriculography revealed a giant false aneurysm (74×75×40 mm) in the inferior wall of the left ventricle with a large orifice (70×58 mm). Repair of the aneurysm was performed under arrested heart, closing the large orifice with a Hemashield patch. Postoperative pathological examination proved that the wall of the aneurysm had myocardial tissue. The microscopic results strongly suggested that this aneurysm was a pseudo-false aneurysm.     

Coronary artery bypass grafting for a very rare run off case of superdominant left anterior descending artery

A superdominant left anterior descending artery (LAD) was found in a 59-year-old man who had electrocardiographic evidence of acute anterior and inferior wall myocardial infarction. Coronary cineangiography showed 95% stenosis at segment 7 of LAD which extended around the apex, ascending into the posterior interventricular sulcus to the crux and ran to the left into posterior atrioventricular sulcus. Posterior descending artery was not provided by the left circumflex artery or the right coronary artery. Multiple infarction due to proximal disease of such a superdominant LAD is very rare in pathoanatomically. Coronary artery bypass grafting to the LAD using left internal mammary artery was performed. The patients is now doing well with no anginal attack, 18 months following the operation.     

Septal wall motion. Its significance on outcome of left ventricular scar resection

To assess the importance of septal wall motion on patient outcome after resection of large akinetic and dyskinetic segments of left ventricle, the records of 70 patients undergoing left ventricular scar excision alone or in combination with myocardial revascularization procedures between January 1970 and January 1977 were reviewed. Patients requiring simultaneous prosthetic valve replacement were excluded. Preoperative left anterior oblique ventriculograms categorized this series of patients into two distinct groups, group A (36 patients) having normal septal wall motion and group B (34 patients) having akinetic or dyskinetic septal walls. Indications for operation and preoperative ejection fractions were similar in both groups. Analysis of these patients subjected to surgery with and without preoperative evidence of septal wall motion demonstrated no significant difference in either functional clinical capacity or in mortality. Mortality for both groups was 11%. Absence of ventricular septal wall motion has no significant effect on outcome of left ventricular scar resection and should not be used as a contraindication to surgery.     

Congenital aneurysm of the left atrial appendage

Aneurysm of the left atrial appendage (LAA) is very infrequent. We present the case of 24-year-old man in functional class I with atrial fibrillation but no other symptoms. Radiology showed an abnormality in the outline of the heart. Echocardiography revealed left appendage aneurysm. After median sternotomy, aneurysmectomy was performed under cardiopulmonary bypass without cross clamping. Atrial fibrillation ceased as soon as the aneurysm had been removed. There were no postoperative complications. Three months later the patient remained asymptomatic and in sinus rhythm.