Case
A 47-year-old male patient came to our hospital with an acute onset of chest pain and was diagnosed with anterior wall myocardial infarction (MI) which was managed conservatively. Four weeks later he came to his physician with a complaint of heaviness in chest since 12 hrs. Transthoracic echocardiogram (TTE) revealed a large 12x10cm pseudoaneurysm located at the left ventricular (LV) apex that communicated with the pericardial cavity through a 24mm defect (Figure 1; Video 1). Flow across the defect was confirmed by color flow Doppler (Figure 2; Video 2). Coronary angiography revealed complete occlusion of the left anterior descending artery. Emergency surgery was planned in view of massive LV pseudoaneurysm. After the induction of anesthesia, a median sternotomy was done. A large LV apical pseudoaneurysm was visualized which was contained by a thick, densely adherent fibrous capsule of the pericardium. The Cardiopulmonary bypass (CPB) was initiated after systemic heparinization. After aortic cross-clamp, a complete dissection of the heart was performed, to avoid systemic embolization. Antegrade cold blood cardioplegia was delivered to arrest the heart. The aneurysm sac was opened by a longitudinal incision (Figure 3). The defect was located close to the apex of the LV, which was closed with a Gore-Tex patch to avoid possible distortion of the heart structures. Bioglue was applied over it and the patient was taken off bypass. The CPB was terminated with ionotropic support of milrinone 0.4mcg/kg/min and noradrenaline of 0.05mcg/kg/min. The patient was successfully shifted to the intensive care unit with stable hemodynamics and the trachea was extubated after 24 hours. A written informed consent was taken from the patient and the case was approved by the institutional review board.