Late Diagnosis of Large Left Ventricular Pseudoaneurysm after Mitral Valve Replacement and Coronary Artery Bypass Surgery by Real-Time Three-Dimensional Echocardiography
A 74-year-old female with a history of coronary artery disease was admitted to our hospital with a history of exertional dyspnea (function class II) during recent months. She had a past history of CABG and MVR surgery approximately 10 months prior to her admission.\nThe postoperative echocardiography, performed one week after surgery, showed mild LV hypertrophy with an ejection fraction of 50%, a prosthetic MV with an acceptable gradient, and a normal right ventricle size with a good systolic function.\nOn present admission, the patient’s pulse rate was 90 per minute and regular, and her blood pressure was 130/70 mm Hg. The patient had 1+ edema in her lower limbs. Auscultation revealed fine crackles in both lung bases and III/VI systolic murmur. An electrocardiogram (ECG) showed left bundle branch block and inverted T wave in V5–V6 leads.\nTTE showed a large echolucent space with a narrow neck (about 1.8 - 2 cm in diameter) on the basal posterolateral portion of the LV (near the prosthetic MV) and the diameter of the cavity was about 70 mm, suggestive of a large pseudoaneurysm in the basal posterolateral portion of the LV with a to-and-fro flow on color Doppler ( and ). RT 3D TTE (Vivid 7 / GE / RT 3D probe) was performed in order to better reveal the spatial relations between the pseudoaneurysm and the adjacent cardiovascular and thoracic structures and to better delineate the pseudoaneurysm borders before surgery. RT 3D TTE showed a large pseudoaneurysm (80 × 52 mm), parallel to the free wall of the LV (). Its orifice was about 20 mm and was very close to the MV annulus.\nThe patient underwent urgent surgery through median sternotomy using cardiopulmonary bypass. After mid sternotomy and moderate hypothermia (28 °C), the left atrium was opened. The prosthetic MV (St Jude #27) remained intact, but the orifice of the LV pseudoaneurysm was unclear when visualized through the St Jude valve. The prosthetic MV was removed. In the posterolateral aspect of the LV just below the annulus of the MV, the large orifice of the pseudoaneurysm (about 20 mm in diameter) was found, which was closed with a pericardial patch (). After the closure of the defect,MVR with a bileaflet mechanical valve (St. Jude # 27) was performed and the patient was weaned from CPB without problems. Post-pump intraoperative transesophageal echocardiography confirmed the complete closure of the orifice of the pseudoaneurysm without a flow. The postoperative course was acceptable and the patient was discharged on 10th postoperative day. TTE was performed before discharge and showed the prosthetic MV with an acceptable gradient, without paravalvular leak and a large echomixed cavity (7 × 3.8 cm) due to a previous pseudoaneurysm posterolateral to the LV, which was filled by a clot. At one year’s follow-up, the patient was in good condition and was taking oral medications.