CASE REPORT
A 69-year-old male patient sought care in a cardiology emergency room for dyspnea, orthopnea and progressive edema of the lower limbs in the last months, with worsening of the condition. His pathological history revealed hypertension, ex-smoker (125 pack years), congestive heart failure and AMI about 1 month ago.
The patient was taking enalapril, bisoprolol, furosemide and rosuvastine. Upon physical examination on admission, he was in regular general condition, pale, anicteric and acyanotic. Physiological breath sounds with fine bilateral bursts audible in bases and middle third. Dyspneic, with 98% O2 saturation in room air, not able to lie down. In the evaluation of cardiovascular system, regular heart sounds (S1, S2), without murmurs. Well-perfused ends.
Laboratory tests, electrocardiogram, transthoracic echocardiogram and cinecoronarioangiography (due to the history of AMI) were requested. The exams revealed hemoglobin 11.8 g/dl, hematocrit 37.0%, platelets 306,000, INR (International Normalized Ratio) 1.20 and troponin 0.02. Admission electrocardiogram shows regular sinus rhythm with pathological Q waves in the inferior wall.
Transthoracic echocardiogram revealed significant left ventricular systolic dysfunction, with an ejection fraction of 31%. In addition, an extensive pseudoaneurysm involving the apical region, measuring 96x116 mm with neck measuring 35 mm, associated with a diffuse moderate-sized pericardial effusion, with its largest layer measuring 16 mm, adjacent to the right cardiac cavities, with incipient signs of hemodynamic repercussion.
As an urgent matter for coronary evaluation, it was decided to perform cinecoronarioangiography. A right coronary flow pattern was described, as well as a 40% calcified lesion in the proximal third of the right coronary. The anterior descendant exhibits marked 40% calcification of the proximal third with a 50% segmental lesion in the middle third. Circumflex artery had severe atheromatosis in its proximal third and occlusion in the middle third.
The patient was referred to the operating room, where the left common femoral artery was dissected and the right femoral vein was punctured. Heparinization and cannulation of these vessels were performed. In cardiopulmonary bypass, due to the risk of rupture, a hypothesis suggested by the presence of pericardial effusion on the preoperative echocardiogram, a median transsternal thoracotomy was performed, and the right great saphenous vein was dissected. In the intraoperative period, an important ventricular pseudoaneurysm was seen, however, there was no evidence of the pericardial effusion described on preoperative echocardiogram (Figure 1)
The pseudoaneurysm was approached through a circular incision bordering the normal wall. The cavity was disproportionate to the size of the left ventricle. Cerclage of the edge with fibrotic aspect was performed to reduce the orifice (Figure 2). The orifice, anchored in felt strips, was sutured with 16 stitches using polypropylene 3-0, followed by implantation of bovine pericardium with 3 layers. Finally, a linear suture was performed on the remaining tissue for better hemostatic control (Figure 3).