Submitral Ventricular Pseudoaneurysm: Unusual and Late Complication of Cardiac Surgery

Despite the background of advances in cardiac surgery procedures for higher risk population, the postoperative complication has already been a challenge for cardiac surgeon and Heart-Team. Future perspectives to exceed this challenge could be periodically patient’s follow up and advance diagnostic workup. We describe the diagnosis of a large sub mitral left Ventricle Pseudoaneurysm that was identifi ed in a 59-yearold woman 17 years after she underwent aortic and mitral valve replacement for rheumatic valvular disease. Case Report


INTRODUCTION
Left ventricle pseudoaneurysm (LVP) after cardiac surgery is uncommon and rare postoperative complication and its cause is not clear. The LVP could be de ined sub aortic, sub mitral and intervalvular when developed in theinter annular zone between the mitral and aortic [1][2][3][4]. An early multimodality diagnostic workup up could reduce morbidity and mortality hence increasing related survival of the patients suffering of ibrosa LVP. We presented a 59-year-old woman with sub mitral left ventricle pseudoaneurysm occurring 17 years after cardiac surgery.

CASE REPORT
A 59-years-old Caucasian female was admitted to our Institution with dyspnea and asthenia since few months. Her cardiac history revealed successful mechanical aortic and mitral valve replacement. A standard transthoracic echocardiography (TTE) showed an echogenic image involving basal segment of lateral wall with de ined edges adjacent to Left Ventricular Out low Tract (LVOT) in the region of the mitralaortic junction with no LVOT gradient and/or shunts, suggesting for sub mitral left ventricle pseudoaneurysm ( Figure 1 a and b). Left ventricle ejection fraction (LVEF) was 30%, the stroke volume (SV) 40 ml/beat, LV end diastolic volume (LVEDV) 182 ml, LV end sistolic volume (LVESV) 128 ml, sPAP 42 mmHg (Figure 1c). To better understand the relationship with the nearest cardiac structure, a Cardiac Multi Detector 64-slice Computed Tomography (MDCT-64) was performed demonstrating giant left ventricular pseudoaneurysm (10 × 6 cm) originating from the posterior mitral valve annulus ( Figure 2). According to patient clinical history, the sub mitral LV pseudoaneurysm could be a late and rare cardiac surgery complication after the previous mitral valve replacement. Considering the clinical and diagnostic overview of the patient and the surgical risk, discussing the case to the Department Heart Team (Euro score II 9.02%, STS score risk of mortality 8,68%, Morbidity or mortality 35,48%, Prolonged Ventilation 23%), wesuggested the surgical intervention but the patient refused. She was regularly visited in the outpatient department and at the moment she was NYHA II.

DISCUSSION AND CONCLUSION
The sub mitral LV pseudoaneurysm (SLVP) is a rare condition that has been   reported as a result of endocarditis, chest trauma or heart valve surgery. Endocarditis and aortic valve surgery are the two most frequent causes (0.02-2% of cardiac surgery postoperative complications). The pathophysiology of SLVP is multiple: congenital (weak and thin membranous region in the sub-mitral location caudal to the posteromedial segment of the mural lea let and adjacent aortic lea let of the mitral); the infection such as endocarditis caused the distortion and thinning of mitral-aortic interventricular groove; previous heart surgery, in particularly mitral or aortic valve replacement, caused modi ication of heart geometry and tension on ventricle.
Complications of SLVP include istula formation, such as perforation with shunt of LVOT into the left atrium, infection, compression of the coronary or pulmonary arteries, also increase of size with the possibility of rupture, embolization, or primary valvular dysfunctions [3] ( Table 1). Before therapeutic choice (medical, surgical or endovascular), it is important the identi ication of size, anatomical relationships and clinical patient' details. The operative risk and the critical issues of the pathology might address the physician to the appropriate choice. In addition, the current multimodality imaging and the future perspective in diagnostic workup might get better the management of these patients, hence the short and long term-survival. We suggested to perform always multimodality workup in suspicious of post-cardiac surgery LV pseudoaneurysm to have the best imaging sensibility and speci ity in diagnosis hence to have much more information for therapeutic choice and patient-safe.
The principal surgical approach is the median sternotomy and consequently the exclusion of SLVP by direct suture or patch positioning. According to O' Flynn et al. [4] and Namboodiri et al. [5] the direct closure of the ori ice located outside the LV and outside the LV under thoracotomy or could be the available, safe and less invasive approach to do. On the contrary, Honda and colleagues [6] supported the conventional approach and surgical technique by closing the pseudoaneurysm with a patch and the median sternotomy approach ( Table 2). The early surgical repair is often the recommended treatment, in particularly if the heart failure is present and the pseudoaneurysm size is more than 3 cm in diameter ( Table 2) in order to reduce the risk of rupture or infection or compression of neighboring structures. Therefore, the most incidence of SLVP are in patient with a clinical history of previous cardiac surgery, hence the less invasive approach could be the safer and the more effective. Moreover a new therapeutic choice is spreading against surgery: endovascular choice has been taking place more and more in daily clinical work according to clinical and diagnostic features of the patients. According to our experience, in case of low SLVP size, and/or no infectious sign (increasing of white blood cell, negative in lammation index such as C-reactive protein and pro calcitonin) and/or high operative risk, the conservative choice is better with a short follow up. On the other hand, the surgical choice excluded de initively the pathology and the risk of SLVP rupture but has got technical risk, peri-and postoperative risks. Moreover, in the perspective of the SLVP therapy we have a new reliable and wide spreading choice: endovascular.