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• W2057120983 abstract "In a 57-year-old man with Wolff-Parkinson-White syndrome, a left ventricular pseudoaneurysm developed, induced by the pop phenomenon, after radiofrequency catheter ablation of the posterolateral accessory pathway. The pseudoaneurysm was positioned at the atrioventricular groove with moderate pericardial adhesions, and the rupture site was located just below the P3 annulus of the posterior mitral leaflet. With this anatomy and in the presence of adhesions, we repaired the rupture site from within the heart through an incision made in the posterior mitral leaflet. This transmitral approach might be a reasonable surgical option for treating this type of submitral left ventricular pseudoaneurysm. In a 57-year-old man with Wolff-Parkinson-White syndrome, a left ventricular pseudoaneurysm developed, induced by the pop phenomenon, after radiofrequency catheter ablation of the posterolateral accessory pathway. The pseudoaneurysm was positioned at the atrioventricular groove with moderate pericardial adhesions, and the rupture site was located just below the P3 annulus of the posterior mitral leaflet. With this anatomy and in the presence of adhesions, we repaired the rupture site from within the heart through an incision made in the posterior mitral leaflet. This transmitral approach might be a reasonable surgical option for treating this type of submitral left ventricular pseudoaneurysm. Submitral left ventricular (LV) pseudoaneurysm is a rare condition that can occur after inferior myocardial infarction or mitral valve replacement [1Frances C. Romero A. Grady D. Left ventricular pseudoaneurysm.J Am Coll Cardiol. 1998; 32: 557-561Abstract Full Text Full Text PDF PubMed Scopus (417) Google Scholar]. Submitral LV pseudoaneurysm induced by radiofrequency (RF) catheter ablation is exceedingly rare. The present report documents such an occurrence, and describes our experience with transatrial repair of the submitral LV pseudoaneurysm. A 57-year-old man with Wolff-Parkinson-White syndrome was referred to us after RF catheter ablation owing to the development of a submitral LV pseudoaneurysm. The pseudoaneurysm was induced by the pop phenomenon during RF catheter ablation of the posterolateral accessory pathway. Computed tomography (CT) showed the pseudoaneurysm to be 15 × 15 mm in size and to be located on the posterior aspect of the left ventricle (Fig 1). Transesophageal echocardiography showed that the pseudoaneurysm was connected to the LV cavity and that the rupture site, which had a diameter of 4 mm, was just below the P3 annulus of the posterior mitral leaflet. Mitral regurgitation was not detected. The patient had two episodes of cardiogenic shock caused by the cardiac tamponade that resulted from rupture of the pseudoaneurysm. The first cardiogenic shock was treated successfully by pericardiocentesis. When cardiogenic shock recurred, however, an urgent operation was scheduled on the 23rd day after RF catheter ablation. After a midsternal incision and pericardiotomy, bloody pericardial fluid appeared. Moderate pericardial adhesions were present. Cardiopulmonary bypass was initiated with ascending aortic and bicaval cannulation. After cross clamping of the ascending aorta, a single dose of cold blood cardioplegia was injected into the aortic root. The mitral valve was accessed by a septal-superior incision. The surface of P3 was observed to show a reddish discoloration. However, the mitral complex was intact. An incision 15 mm in length was made in P3 parallel to its annulus to gain exposure to the rupture site. Through this opening, a 5-mm diameter rupture site of the left ventricle was seen just below the annulus of P3 (Fig 2A). The ventricular musculature surrounding this area was very fragile. Therefore, we closed it with three pairs of 3-0 Prolene mattress sutures (Ethicon, Somerville, NJ) supported by autopericardial strips. We also partially used the annulus of P3 for closing the rupture site. The strips of pericardium were used on each side of the aneurysm neck, and the neck was closed directly with these strips of pericardium (Fig 2B). The incision into P3 was closed with a 5-0 Ethibond running suture (Ethicon). The patient was weaned off the cardiopulmonary bypass without difficulty. Aortic cross-clamp and cardiopulmonary bypass times were 79 minutes and 164 minutes, respectively. An intraoperative transesophageal echocardiography showed the pseudoaneurysm was no longer connected to the LV cavity. However, mild mitral regurgitation from P3 was detected. A postoperative CT on the 14th day showed that the pseudoaneurysm was no longer present. The patient was discharged from the hospital in ambulatory condition on the 57th postoperative day after occupational rehabilitation. At the 1-year follow-up, transesophageal echocardiography showed the disappearance of the pseudoaneurysm. Mitral regurgitation had improved and could be classified as trivial. In this case, the mechanism of occurrence of the submitral LV pseudoaneurysm was thought to be the pop phenomenon. This phenomenon is caused by an excess rise of temperature in the myocardium during RF catheter ablation. In this condition, steam forms and expands within the myocardium [2Dorwarth U. Fiek M. Remp T. et al.Radiofrequency catheter ablation: different cooled and noncooled electrode systems induce specific lesion geometries and adverse effects profiles.Pacing Clin Electrophysiol. 2003; 26: 1438-1445Crossref PubMed Scopus (90) Google Scholar]. Subsequently, this causes a focal blast, and a crater is generated within the myocardium. This steam pop phenomenon is noted occasionally, and it can lead to perforation of the myocardium depending on the severity. Therefore, RF catheter ablation is most often performed in a temperature-controlled mode. However, the ablation electrode temperature is dependent on the opposing effects of heating from the tissue and cooling by the blood flowing around the electrode [3Yokoyama K. Nakagawa H. Wittkamp F.H. Pitha J.V. Lazzara R. Jackman W.M. Comparison of electrode cooling between internal and open irrigation in radiofrequency ablation lesion depth and incidence of thrombus and steam pop.Circulation. 2006; 113: 11-19Crossref PubMed Scopus (193) Google Scholar]. The ablation electrode temperature sometimes does not reflect the true temperature within the myocardium [4Tracy C.M. Moore H.J. Solomon A.J. et al.Effective temperatures at sites of atrial insertion accessory pathway ablation [Abstract].J Am Coll Cardiol. 1993; 21: 173AAbstract Full Text PDF Scopus (166) Google Scholar]. Therefore, there is the possibility of an excess rise of temperature within the myocardium. This phenomenon is an infrequent complication of RF catheter ablation, but can occasionally lead to critical myocardial rupture. Surgical treatment has been recognized as appropriate because pseudoaneurysms, unlike true aneurysms, are liable to fatal rupture [1Frances C. Romero A. Grady D. Left ventricular pseudoaneurysm.J Am Coll Cardiol. 1998; 32: 557-561Abstract Full Text Full Text PDF PubMed Scopus (417) Google Scholar]. Accordingly, we elected to carry out surgical treatment for this patient who had a history of two episodes of cardiac tamponade. In the past, LV pseudoaneurysms after myocardial infarction have customarily been repaired through the free wall of the pseudoaneurysm, the so-called conventional ventricular approach [5Schrire V. Barnard C.N. The surgical cure of a cardiac aneurysm of unknown cause.J Cardiovasc Surg (Torino). 1963; 4: 5-10PubMed Google Scholar]. However, this approach does not allow easy access to the posterior subvalvular area because of the variable direction of expansion of the pseudoaneurysm and the occurrence of pericardial adhesions. In two previous reports, Antunes and coworkers [6Antunes M.J. Submitral left ventricular aneurysms Correction by a new transatrial approach.J Thorac Cardiovasc Surg. 1987; 94: 241-245PubMed Google Scholar] and Jahangiri and colleagues [7Jahangiri M. Sarkar D. Quinton P. Ward D.E. Submitral left ventricular pseudoaneurysm.Ann Thorac Surg. 2005; 79: 1031-1032Abstract Full Text Full Text PDF PubMed Scopus (6) Google Scholar] have utilized a transatrial approach to this repair. The Antunes transatrial approach was mainly performed on an African black population with congenital submitral LV true aneurysms located behind the left atrium. Antunes successfully directly closed the aneurysmal neck located below the posterior mitral annulus through an orifice created by an incision in the floor of the left atrium. On the other hand, Jahangiri and coworkers [7Jahangiri M. Sarkar D. Quinton P. Ward D.E. Submitral left ventricular pseudoaneurysm.Ann Thorac Surg. 2005; 79: 1031-1032Abstract Full Text Full Text PDF PubMed Scopus (6) Google Scholar] reported a variation of the transatrial approach to a posterior submitral LV pseudoaneurysm that occurred after a myocardial infarction. Because the pseudoaneurysm was situated in a posterior and inferior location just below the posterior mitral leaflet and was accompanied by severe pericardial adhesions, Jahangiri approached the rupture site through the mitral orifice. He divided the posterior papillary muscle to gain exposure to the rupture site and successfully made a patch closure. The divided posterior papillary muscle was repaired without causing mitral regurgitation. Similar to the method used by Jahangiri, we approached the rupture site from within the heart because of the position of the pseudoaneurysm and the presence of moderate pericardial adhesions. The rupture site was easily closed through the opening obtained by an incision in the posterior mitral leaflet. Trivial postoperative mitral regurgitation might result from distortion of the posterior mitral annulus when direct closure is employed. Wolpowitz and coworkers[8Wolpowitz A. Arman B. Barnard M.S. Barnard C.N. Annular subvalvular idiopathic left ventricular aneurysms in the black African.Ann Thorac Surg. 1979; 27: 350-355Abstract Full Text PDF PubMed Scopus (20) Google Scholar] reported the occurrence of postoperative mitral regurgitation necessitating mitral valve replacement after direct closure in the presence of a posterior subvalvular aneurysm. Accordingly, in such cases, we consider it appropriate to utilize application of a patch closure to avoid distortion of the mitral valve. Although our experience is limited, this transatrial approach might be one of the surgical options for treating submitral LV pseudoaneurysm with pericardial adhesions." @default.
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• W2057120983 title "Transatrial Repair of Submitral Left Ventricular Pseudoaneurysm" @default.
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