European Journal of Cardiovascular Medicine

Left ventricular (LV) pseudoaneurysm is a rare but serious complication that results from a contained rupture of the myocardial wall, typically bound by pericardial adhesions or thrombus rather than myocardium itself. ^[1] Unlike true aneurysms, which involve all three layers of the ventricular wall, pseudoaneurysms lack structural integrity and are at high risk of rupture, leading to life-threatening complications. ^[2] The condition predominantly arises following transmural myocardial infarction (MI) but may also be associated with cardiac surgery, trauma, infective endocarditis, or inflammatory pericardial disease. ^[3,4]

Studies have shown that LV pseudoaneurysm is mostly evident between 10 days and 2 months after MI. Although advances in imaging techniques have improved diagnostic accuracy, LV pseudoaneurysms remain a diagnostic challenge due to their often nonspecific clinical presentation, including dyspnea, chest pain, and arrhythmias. ^[5]

Early identification is critical, as untreated pseudoaneurysms have a reported rupture rate of 30-45%, resulting in high mortality. ^[6] Echocardiography remains the first-line imaging modality, but cardiac magnetic resonance imaging (CMR) and computed tomography angiography (CTA) provide superior anatomical delineation and differentiation from true aneurysms. ^[7,8] Surgical repair remains the gold standard treatment, especially for symptomatic or enlarging pseudoaneurysms, with patch closure being the most widely used technique. ^[9,10]

This study builds upon our previous research and presents an updated, single-center experience with LV pseudoaneurysm management. By incorporating additional cases, we aim to provide a more comprehensive evaluation of clinical characteristics, diagnostic approaches, and surgical outcomes, offering further insight into the optimal management strategies for this complex condition.

This study presents a retrospective analysis of patients diagnosed with left ventricular (LV) pseudoaneurysms who underwent surgical intervention at our center between May 2009 to December 2024. The common symptoms were chest pain and dyspnea Medical records, imaging reports, and intraoperative findings were reviewed to assess clinical presentation, diagnostic approach, surgical technique, and postoperative outcomes. The inclusion criteria were patients with confirmed LV pseudoaneurysm diagnosed through imaging and intraoperative findings, who underwent surgical repair. Patients with non-cardiac pseudoaneurysms or those managed conservatively were excluded from the analysis.

Diagnostic Assessment

All patients underwent a structured diagnostic workup to confirm the presence of an LV pseudoaneurysm. Initial screening was performed using transthoracic echocardiography (TTE), followed by contrast-enhanced computed tomography (CECT) or cardiac magnetic resonance imaging (CMR) in cases where further anatomical delineation was required. Coronary angiography was performed in patients with suspected ischemic etiology to assess concomitant coronary artery disease. Fig1

Surgical Technique

All patients underwent surgical repair via median sternotomy under general anesthesia with moderate hypothermic cardiopulmonary bypass (CPB). The standard aorto-bicaval cannulation technique was used, and myocardial protection was achieved using antegrade Del Nido cold blood cardioplegia. To prevent systemic embolization, the aorta was cross-clamped first and then dissection was done. The pseudoaneurysm cavity was accessed via an epicardial or transatrial approach, depending on its anatomical location and proximity to adjacent structures. Following clot evacuation, the pseudoaneurysm neck was reinforced with a synthetic (polytetrafluoroethylene [PTFE] or Dacron) or autologous pericardial patch. Additional procedures, such as mitral valve repair/replacement or coronary artery bypass grafting (CABG), were performed in patients with concomitant mitral regurgitation or coronary artery disease.

We followed clinical parameters (e.g. good cardiac contractility, central venous pressure and hemodynamic stability) as a guide for weaning from CPB, instead of the principle of fixed reperfusion time (~one-third of cross clamp time) before weaning from CPB as followed at some centers. Primary closure of sternotomy was done in all cases. None of the patients needed mechanical circulatory support in the post-operative period. All patients were shifted from the operating room (OR) to the intensive care unit (ICU) on mechanical ventilation and inotropic support. Fig 2,3

Figure 1: X-ray shows cardiomegaly with ill-defined apical region.

Figure 2: Left ventricular pseudoaneurysm. A, Apical 4-chamber view of of transthoracic echocardiography. B, Cardiac magnetic resonance imaging coronal view. C, Cardiac magnetic resonance imaging axial view. D, Intraoperative image. E, Two-chamber mid-esophageal view of transesophageal echocardiography with flow. F, Apical 4-chamber view of transthoracic echocardiography after repair.

Figure 3: A Visualization of pseudoanurysm sac. b Pseudoaneurysm sac seen to communicate with left ventricle

Postoperative Care and Follow-up

All patients were monitored in the intensive care unit (ICU) postoperatively, with inotropic support as needed. Extubation was performed based on hemodynamic stability and respiratory function. Serial echocardiography was conducted to assess ventricular function and confirm the integrity of the repair. Patients were discharged once they achieved hemodynamic stability and satisfactory recovery. Follow-up evaluations were conducted postoperatively with ECHO, with to monitor for recurrence or residual aneurysmal changes.

Statistical Analysis

Data were analyzed using SPSS V26 software. The qualitative variables were expressed as percentages, while the quantitative variables were expressed as mean ± 2 S.D

Patient Demographics and Clinical Characteristics

A total of 11 patients who underwent surgical repair for left ventricular (LV) pseudoaneurysm at our center between May 2009 to December 2024 were included in the study. The mean age was 38.7 years (range: 7–73 years), with 9 males and 2 females. The most common etiology was myocardial infarction (6 patients, 54.5%), followed by infective causes (4 patients, 36.4%) and trauma-related pseudoaneurysm (1 patient, 9.1%). The mean ejection fraction (EF) preoperatively was 47.2%, and most patients were classified as NYHA III at the time of presentation. [Table 1: Patient Demographics and Clinical Characteristics]

Surgical Approach and Intraoperative Findings

Surgical repair was performed via median sternotomy in all cases, utilizing cardiopulmonary bypass with moderate hypothermia. The surgical approach was predominantly epicardial (6 patients, 54.5%), followed by transatrial (3 patients, 27.3%) and left ventriculotomy (2 patients, 18.2%). Closure of the pseudoaneurysm was achieved using pericardial patches (4 patients, 36.4%), PTFE patches (5 patients, 45.4%), and Dacron patches (2 patients, 18.2%). Additional procedures, such as mitral valve repair/replacement (3 patients, 27.3%), coronary artery bypass grafting (CABG) (2 patients, 18.2%), VSD closure (2 patients,18.2%) were performed in select cases. The mean aortic cross-clamp time was 132 minutes, and the mean CPB duration was 188 minutes. [Table 2: Surgical Approach and Intraoperative Findings]

Postoperative Outcomes and Follow-up

All patients had uneventful postoperative recovery, except for one mortality (9.1%) due to acute exacerbation of chronic obstructive pulmonary disease (COPD) at 15 months post-surgery. The mean ICU stay was 49.4 hours, and the mean hospital stay was 4.5 days. Postoperative EF remained stable or improved in all patients, with the majority being NYHA I or II at discharge. The mean follow-up duration was 13 months (range: 3–36 months), with no reported cases of pseudoaneurysm recurrence or surgical revision. [Table 3: Postoperative Outcomes and Follow-up]

Table 1: Patient Demographics and Clinical Characteristics

Table 2: Surgical Approach and Intraoperative Findings

Table 3: Postoperative Outcomes and Follow-up

Left ventricular (LV) pseudoaneurysm is a rare but life-threatening condition characterized by a rupture of the myocardial wall contained by pericardial adhesions or thrombus, lacking a true myocardial layer. ^[1] Its clinical presentation varies widely, making early diagnosis challenging. This study expands upon our previous findings, integrating additional cases to provide a broader perspective on the surgical management and long-term outcomes of LV pseudoaneurysm repair.

Etiology and Risk Factors

In our series, the predominant etiology of LV pseudoaneurysm was myocardial infarction (MI) (54.5%), consistent with existing literature reporting MI as the leading cause in 55–65% of cases. ^[2,3] Other causes included infective endocarditis (36.4%) and blunt chest trauma (9.1%), an etiology that has been infrequently reported but remains a significant risk factor in younger individuals following high-impact injuries. ^[4] Infectious causes, such as pericarditis and endocarditis, contribute to pseudoaneurysm formation due to tissue necrosis and subsequent cavity formation within the myocardium. ^[5,6]

Diagnostic Modalities and Challenges

Early identification is critical, as pseudoaneurysms carry a 30–45% risk of rupture, necessitating urgent intervention. ^[7] Transthoracic echocardiography (TTE) was the primary screening modality in all patients, while contrast-enhanced computed tomography (CECT) and cardiac magnetic resonance imaging (CMR) were used in cases requiring further anatomical delineation. Our findings align with prior studies emphasizing the role of CMR in differentiating pseudoaneurysms from true aneurysms. ^[8] Coronary angiography was also performed in patients with ischemic etiology, helping identify significant coronary artery disease (CAD), a factor influencing the surgical approach. ^[9]

Surgical Techniques and Outcomes

Surgical repair remains the gold standard for LV pseudoaneurysm management, given the high risk of rupture with conservative therapy. ^[10] In our study, surgical approaches varied based on the location and etiology of the pseudoaneurysm. The epicardial approach (54.5%) was preferred for pseudoaneurysms with accessible necks, while transatrial (27.3%) and left ventriculotomy (18.2%) were used for cases involving sub-mitral aneurysms or complex anatomical locations.

Patch closure was the most common repair technique, using PTFE, Dacron, or autologous pericardium, with material selection based on surgeon preference and underlying pathology. Pericardial patches were favored in cases of infective pseudoaneurysms to reduce the risk of reinfection, while synthetic materials (PTFE, Dacron) were used in ischemic cases for structural integrity. ^[11]

Concomitant procedures were necessary in 5 patients, including mitral valve interventions (27.3%), CABG (18.2%) & VSD closure (18.2%) highlighting the complexity of surgical planning in patients with multiple cardiac pathologies. Notably, our results show a mean aortic cross-clamp time of 132 minutes and a mean CPB time of 188 minutes, values comparable to other surgical series in the literature. ^[12]

Postoperative Outcomes and Follow-Up

Our findings indicate favorable short-term and mid-term surgical outcomes, with no perioperative mortality and one late mortality (9.1%) due to exacerbation of chronic obstructive pulmonary disease (COPD) rather than cardiac complications. This aligns with existing literature reporting operative mortality rates of 5–15% but improved outcomes with early surgical intervention. ^[13,14]

Functional recovery was also promising, with 90.9% of patients in NYHA I or II at discharge, indicating significant symptomatic improvement post-surgery. Mean ICU stay (49.4 hours) and hospital stay (4.5 days) were relatively short compared to earlier reports,likely due to advancements in perioperative care and early mobilization protocols. ^[15]

During follow-up (mean: 13 months, range: 3–36 months), no pseudoaneurysm recurrence was observed, suggesting that meticulous surgical technique and appropriate patch selection contribute to long-term stability. While longer follow-ups are necessary, these outcomes highlight the efficacy and durability of surgical repair in LV pseudoaneurysms.

Clinical Implications

Given the high morbidity and mortality associated with untreated LV pseudoaneurysms, our findings reinforce the need for early diagnosis and prompt surgical intervention. Additionally, the choice of surgical approach and patch material should be individualized, considering factors such as etiology, anatomical location, and presence of concomitant valvular or coronary disease. Our results also suggest that advancements in perioperative care and imaging modalities have contributed to improved survival rates and functional outcomes.

LV pseudoaneurysm remains a rare but serious cardiac condition requiring early recognition and timely surgical management to prevent catastrophic rupture. Our study highlights myocardial infarction as the leading etiology, followed by infective causes and trauma-related pseudoaneurysms. A high index of clinical suspicion and routine echocardiographic screening for detection of LV pseudoaneurysm are essential to improve the out come in these patients. Surgical repair with patch closure remains the preferred treatment strategy, with low perioperative mortality and favorable long-term functional outcomes. Future studies with larger cohorts and extended follow-up periods are necessary to refine surgical techniques and optimize long-term prognosis in this high-risk patient population.

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