History

A 42-year-old patient was admitted to the emergency department with increasing dyspnea for three weeks. On admission, the patient was awake, orientated and hemodynamically stable with a blood pressure of 120/63 mmHg, a heart rate of 100 bpm and an O₂ saturation of 97%. Laboratory results showed an elevated TNT levels 96 ng/l.

For several months he suffered from tingling and numbness in his left hand and neck and chest pain. He was a heavy smoker (30 cigarettes/day). He did not thought his heart could be sick.

Examination findings

The ECG showed a slow R progression in V1-V3 and persistent ST elevations consistent with previous myocardial infarction.

In the coronary angiography a chronic total occlusion of the proximal left anterior descending artery was visible (Figure 1a). The distal vessel was visible retrogradely after injection in the right coronary artery (Figure 1e). The right coronary and the circumflex artery showed no significant disease.

Further imaging (echocardiography, computed tomography and magnetic resonance tomography) showed an aneurysm of the mid-anterior left ventricular wall (Figure 1b). There was a large thrombus filling this aneurysm intraventricular. Additiontally a perforation at the apical edge of the left ventricular aneurysm could be seen. It was sealed with a second large epicardial thrombus (33x15x55mm). We had an myocardial aneurysma with an additional pseudoaneurysm. The left ventricular ejection fraction was 20%.

The heart team conference recommended a surgical treatment of the pseudoaneurysm. This approach included the possibility of the left ventricular assist device therapy due to both low ejection fraction and reduced left ventricle filling volume after resection of the aneurysm.

Therapy

In the operating theatre, extensive pericarditic areas were evident and the pericardium was fused to the epicardium at the left ventricle. The aneurysmatic apex  of the left ventricle showed a transmyocardial perforation covered by a relatively firm large thrombus. This thrombus and the adjacent thinned myocardium was excised (Figure 1c). Using a glove filled with saline, the remaining filling volume of the left heart chamber was determined, which was well below 50 ml. Therefore, a simple ventricle tightening with not possible with the remaining myocardium.

An individually to the ventricular size adapted patch has been prepared. In this patch the apical connector of a left ventricular assist device was sewn in (Figure 1g). This patch (approx. 8x8 cm) was sewn to the remaining left ventricule to create a larger ventricular cavity. Transesophageal echo demonstrated good positioning of the pump canula within the left ventricle with undisturbed inflow (Figure 1h). The aortic connection of the pump and the drive cable were implanted.

Results

The patient recovered well and was transferred to early rehabilitation. One year after operation ejection fraction improved from 20% to 35% under therapy.

Conclusion

Multimodality imaging showed a thrombosed aneurysm of the left anterior wall with an additionally pseudoaneurysm covered with an epicardial thrombus. Therapy was excision of the thrombosed aneurysm and simultaneously the implantation of a left ventricular assist device. By sewing the apical connector into the left ventricular patch the ventricle size could be maintained and the remaining myocardium could be preserved. This case shows that thoughtful planning with multimodality imaging is mandatory in unusual cases.