ventricular septal defect from right to left using pledgetson the right ventricular side of the septum posteriorly.The through-and-through ventricular suture techniqueproposed by Ito and colleagues is interesting and may wellhave merit, although clearly the experience with this tech-nique needs verification. The authors do accurately identifya point of vulnerability in Tirone David’s repair and haveproposed a potentially practical solution to that problem.

Willard M. Daggett, MD

Department of SurgeryMassachusetts General HospitalBulfinch 119Boston, MA 02114e-mail: dailey.stephanie@mgh.harvard.edu.

Surgical Treatment of a Chest-WallPenetrating Left VentricularPseudoaneurysmMatthias Bauer, MD, Michele Musci, MD, MiralemPasic, MD, PhD, Friedrich Knollmann, MD, and RolandHetzer, MD, PhD

Department of Cardiothoracic and Vascular Surgery,Deutsches Herzzentrum, Berlin, Germany

This report describes the treatment of a patient whodeveloped a chest-wall penetrating pseudoaneurysm 3years after coronary bypass grafting and after the resec-tion of a lateral wall left ventricular aneurysm twice. Thepatient presented with a pulsatile tumor in the leftsubmammilar region. Surgery was done in deep hypo-thermia, with femoro-femoral cannulation and via a leftanterolateral thoracotomy. The perioperative course wasuneventful and the patient is still well 5 years aftersurgery.

(Ann Thorac Surg 2000;70:275–6)© 2000 by The Society of Thoracic Surgeons

The development of a pseudoaneurysm is a rare eventafter the resection of a left ventricular aneurysm. In

this case, resection of a lateral wall left ventricular aneu-rysm was done twice prior to the development of thepseudoaneurysm. The pseudoaneurysm was extraordi-nary in size and extended under the skin of the lateralchest wall. There is only one similar case known in theliterature [1]. We describe our surgical technique.

The first manifestation of coronary heart disease in a66-year-old male was myocardial infarction in 1977. Afterdeveloping a lateral wall left ventricular aneurysm, heunderwent an aneurysmectomy and aortocoronary by-

Accepted for publication Nov 23, 1999.

Address reprint requests to Dr Bauer, Department of Cardiothoracic andVascular Surgery, Deutsches Herzzentrum Berlin, Augustenburger Platz1, 13353 Berlin, Germany; e-mail: mbauer@dhzb.de.

Fig 1. Chest x-ray of a pathologically enlarged heart, primarily tothe left.

Fig 2. Computed tomography scan of the chest showing a large leftventricular pseudoaneurysm, which has perforated the chest wall.

275Ann Thorac Surg CASE REPORT BAUER ET AL2000;70:275–6 CHEST-WALL PENETRATING PSEUDOANEURYSM

© 2000 by The Society of Thoracic Surgeons 0003-4975/00/$20.00Published by Elsevier Science Inc PII S0003-4975(00)01272-8

pass at another institution in 1988 and reaneurysmectomyin 1991. The patient presented at our institution in 1994 witha pulsating protrusion and redness in the area of the leftlateral thoracic wall below the mammilla. He was in NewYork Heart Association class III.

Chest x-rays showed the heart to be pathologicallyenlarged, primarily to the left, and exhibiting an aberrantcontour (Fig 1). Cardiac catheterization, echocardiogra-phy, and computer tomography (Fig 2) revealed a later-ally and apically situated pseudoaneurysm with a narrowconnection between the left ventricle and the aneurysm,which perforated the thoracic wall.

The operation was done with femoro-femoral bypass,deep hypothermic cardiac arrest (18°C) with low-flowperfusion (1.5 l/min) through a left anterolateral thora-cotomy. The wall of the false aneurysm was prepared andthe aneurysmal sack opened. The 2 3 2 cm connectionbetween the left ventricle and the false aneurysm wasclosed with several deeply seated 3-0 Prolene U-patchsutures. De-airation was achieved through the ventricu-lar wall defect before complete closure. A drainage con-duit was placed in the pseudoaneurysmal cavity. Under amoderate dose of catecholamine, the patient was weanedfrom extracorporeal circulation. The postoperativecourse was uncomplicated.

We reevaluated the patient 5 years after surgery. Hewas in good general condition without any signs of heartinsufficiency (New York Heart Association class II). Hehad a normal configuration of the heart on computedtomography scan (Fig 3) and echocardiography. Leftventricular ejection fraction was 30%.

Comment

This case report describes a rare complication after theresection of left ventricular aneurysms with the Cooleymethod [2]. Aneurysms situated on the lateral wall of theleft ventricle are also a rare condition [3].

Pseudoaneurysms may occur after myocardial infarc-tion, cardiac surgery, eg, mitral valve replacement, infec-tions, or after trauma [4, 5]. In our case, the pseudoaneu-rysm obviously developed through partial suturedehiscence after aneurysm resection. The first successfulsurgical treatment of a ventricular pseudoaneurysm wasdescribed by Sauerbruch in 1931. It was a right ventric-ular pseudoaneurysm which was opened under the as-sumption that it was a mediastinal cyst [6].

Rao and colleagues [1] reported in 1998 about a 62-year-old man who developed a pseudoaneurysm of theleft ventricle with subcutaneous herniation 14 years afterleft ventricular aneurysmectomy. The operation was un-dertaken with aortoatriocaval cardiopulmonary bypass,moderate systemic hypothermia, and antegrade cold-blood cardioplegic arrest. In our case, because of the twoprevious operations and the spread of the pseudoaneu-rysm under the skin of the lateral chest wall, we per-formed the operation with femoro-femoral cardiopulmo-nary bypass with deep hypothermia, low-flow perfusion,and approached the heart through a left anterolateralthoracotomy.

The surgical treatment of pseudoaneurysms dependupon their origin, size, and local extension. In the case ofprevious heart operations and lateral or apical situatedpseudoaneurysms of great dimension, an operation indeep hypothermic cardiac arrest, with low-flow perfu-sion, through a lateral thoracotomy that avoids resternot-omy, is highly recommended.

We are grateful for editorial assistance from Tonie Derwent.

References

1. Rao MS, Vaijyanath P, Taneja K, Dubey B, Manchanda SC,Venugopal P. Recurrent pseudoaneurysm of the left ventriclewith subcutaneous herniation into the chest wall. Tex HeartInst J 1998;25:309–11.

2. Cooley DA, Henly WS, Amad KH, Chapman DW. Ventricularaneurysm following myocardial infarction: results of surgicaltreatment. Ann Surg 1959;150:595–612.

3. Ruvolo G, Greco E, Speziale G, Di Natale M, Marino B.Surgical repair of pseudo-aneurysm arising from a truechronic aneurysm of the left ventricular lateral wall. EurJ Cardiothorac Surg 1994;8:449–50.

4. Maselli D, Micalizzi E, Pizio R, Audo A, De Gasperis C.Posttraumatic left ventricular pseudoaneurysm due to in-tramyocardial dissecting hematoma. Ann Thorac Surg 1997;64:830–1.

5. Frances C, Romero A, Grady D. Left ventricular pseudoaneu-rysm. J Am Coll Cardiol 1998;32:557–61.

6. Sauerbruch F. Successful surgical correction of an aneurysmof the right cardiac chamber. Arch Klin Chir 1931;167:586–8.

Fig 3. Computed tomography scan of the heart at follow-up exami-nation 5 years after surgery.

276 CASE REPORT BAUER ET AL Ann Thorac SurgCHEST-WALL PENETRATING PSEUDOANEURYSM 2000;70:275–6