The Nature of the Disorder of Function in Chronic Postinfarction Aneurysm of the Left Ventricle

Assessment of left ventricular function in five patients with chronic postinfarction left ventricular aneurysm was carried out at the time of left heart catheterization and compared with that in six normal subjects. One patient was investigated before and after surgical resection of the aneurysm. The presence of the aneurysm placed the left ventricle at a mechanical disadvantage in systole and increased the resistance to diastolic filling (impedance). This was true even in patients with normal cardiac indices who were not badly disabled. Resection of the aneurysm corrected both these abnormalities, and, as well, lowered the time-tension index at a time when calculated left ventricular work was much increased. These differences between normals and patients with aneurysms, and the changes occurring as a result of resection of an aneurysm, show that the presence of the aneurysm places the left ventricle at a mechanical disadvantage in systole as well as altering its diastolic filling characteristics.     

Hybrid repair of a very late, post-aortic coarctation surgery thoracic aneurysm: a case report

ABSTRACT: INTRODUCTION: Local aneurysms after surgical repair of coarctation of the aorta occur mainly in patients surgically treated by Dacron patch plasty during adulthood. The management of these patients is always problematic, with frequent complications and increased mortality rates. Percutaneous stent-graft implantation avoids the need for surgical reintervention. CASE PRESENTATION: We report a case involving the hybrid treatment by stent-graft implantation and transposition of the left subclavian artery to the left common carotid artery of an aneurysmal dilatation of the thoracic aorta that occurred in a 64-year-old Caucasian man, operated on almost 40 years earlier with a Dacron patch plasty for aortic coarctation. Our patient presented to our facility for evaluation with back pain and shortness of breath after minimal physical effort. A physical examination revealed stony dullness to percussion of the left posterior thorax, with no other abnormalities. The results of chest radiography, followed by contrast-enhanced computed tomography and aortography, led to a diagnosis of giant aortic thoracic aneurysm. Successful treatment of the aneurysm was achieved by percutaneous stent-graft implantation combined with transposition of the left subclavian artery to the left common carotid artery. His post-procedural recovery was uneventful. Three months after the procedure, computed tomography showed complete thrombosis of the excluded aneurysm, without any clinical signs of left lower limb ischemia or new onset neurological abnormalities. CONCLUSIONS: Our patient's case illustrates the clinical outcomes of surgical interventions for aortic coarctation. However, the very late appearance of a local aneurysm is rather unusual. Management of such cases is always difficult. The decision-making should be multidisciplinary. A hybrid approach was considered the best solution for our patient.     

Hypertrophic cardiomyopathy associated with left ventricular aneurysm and normal coronary arteries: Case study indicating genetic tendencies of cardiomyopathy

A 50-year-old man presented with hypertrophic obstructive cardiomyopathy (HOC) associated with a left ventricular aneurysm and normal coronary arteries. His history revealed no evidence of myocardial infarction or atypical angina. Physical examination disclosed HOC but did not suggest the presence of an aneurysm. Although the patient was treated medically, heart failure ensued, and he died suddenly while working his farm. Subsequent investigation of the patient's family revealed that three of his five children were also affected by cardiomyopathy, which was especially pronounced in the eldest, a 22-year-old man. The possible hemodynamic relationship between HOC and left ventricular aneurysm is discussed, along with probable indications. The role of left ventricular aneurysm is also presented in relation to the natural history of the disease.     

POST-TRAUMATIC APICAL LEFT VENTRICULAR ANEURYSM IN A PATIENT WITH LEFT VENTRICULAR APICAL-ABDOMINAL AORTIC CONDUIT: CASE PRESENTATION

A patient with a small aortic annulus had an apico-aortic conduit implanted for aortic stenosis approximately three years before being admitted to our institution. Four months after sustaining a steering wheel injury to the chest, he developed chest pain and palpitations. X-ray films and left ventriculograms revealed a large apical aneurysm of unknown duration. At surgery, it was noted that the proximal portion of the conduit had been sewn directly to the myocardium without the use of a rigid or soft apical outlet prosthesis incorporating a sewing ring. The aneurysm was resected along with a small proximal segment of the conduit graft. A polished Pyrolite(R) rigid inlet tube with a sewing ring and graft extension was inserted into the residual left ventricular apex, and continuity was reestablished with the abdominal segment of the conduit. It is postulated that the aneurysm was caused by either the direct anastomosis of the fabric graft to the apical myocardium at the original operation (with subsequent disruption and aneurysm formation prior to the steering wheel injury), or was the result of fixation of the heart at the diaphragm by the conduit, with increased vulnerability to deceleration injury at the direct left ventricular apex myocardium-fabric graft site.     

Poor sensitivity of multiple-gated blood-pool imaging in diagnosing left ventricular aneurysms.

A study was carried out to determine the accuracy of multiple-gated blood-pool imaging in diagnosing left ventricular aneurysm. Fifteen patients with an aneurysm and 17 with left ventricular hypokinesia were studied by contrast ventriculography and multiple-gated blood-pool imaging. The results of blood-pool imaging were examined blind by five independent observers, the results of contrast ventriculography being used as the standard. The mean sensitivity of the procedure was 56%, the specificity 61%, and diagnostic accuracy 59%. These results indicate that contrast ventriculography remains the best method for diagnosing left ventricular aneurysms. Moreover, ventriculography provides additional information-for example, on wall thickness-not provided by multiple-gated blood-pool imaging.     

False left ventricular aneurysm as a complication of open heart surgery.

A false aneurysm developed at the site of left ventricular venting in an 8-year-old boy who had undergone aortic valve commissurotomy under cardiopulmonary bypass. The diagnosis was made by clinical examination and chest radiography and confirmed by left ventricular cineangiography. The aneurysm was successfully resected.     

A Patient-Specific Computational Fluid Dynamic Model of Middle Cerebral Artery Aneurysm Before and One Year After Surgery

Computational fluid dynamics (CFD) has been widely used for studying intracranial aneurysm hemodynamics, while its use for guiding clinical strategy is still in development. In this study, CFD simulations helped inform treatment decision for a middle cerebral artery (MCA) aneurysm case was investigated. A patient with a 10.4 × 9.8 mm aneurysm attached with a small aneurysm at the edge of the trifurcation in the left MCA was included in this study. For removing the MCA aneurysm, two scenarios were considered: Plan-A involved clipping the small aneurysm and Plan-B involved clipping the whole aneurysm. A suitable treatment plan was decided by comparing the clinical measurements and CFD analysis between these two plans. One-year after the surgery, the CFD analysis was conducted again on the post-operative aneurysm model to verify the selected surgical plan in terms of morphometric and hemodynamic properties changes in the aneurysm. Based on the CFD simulation and clinical experience, surgical Plan-A was adopted. One-year after the surgery, both the hemodynamic and morphological properties improved in the post-operative aneurysm model, indicating the recovery of the patient. The patient-specific aneurysm CFD analysis can help to determine a better surgical plan for patients with special cerebral aneurysms. This study showed how CFD analysis can be used to aid clinical diagnosis and treatment.     

Can Right Ventricular Pacing be Useful in the Assessment of Cavo-tricuspid Isthumus Block?

Background

Cavo-tricuspid isthmus (CTI) block is currently assessed by coronary sinus (CS) pacing or low lateral and septal atrial pacing. Occasionally, CS catheterization through the femoral route can be difficult to perform or right atrial pacing can be problematic because of catheter instability or saturation of the atrial electrograms recorded near the catheter.

Objectives

Our aim was to evaluate the feasibility of assessing cavo-tricuspid isthmus block by means of right ventricular (RV) pacing in patients with ventriculo-atrial conduction, comparing it with CS pacing.

Methods

Circumannular activation was analyzed during CS and RV pacing in consecutive patients in sinus rhythm undergoing CTI ablation for typical atrial flutter. Patients without ventriculo-atrial conduction were excluded from the study. The linear lesion was created during RV pacing and split atrial signals on the ablation line were analyzed. CTI block was confirmed by analyzing local electrograms on the line of block and circumannular activation during CS and RV pacing.

Results

Out of 31 patients, 20 displayed ventriculo-atrial conduction (64%) and were included in the study. Before ablation, during RV stimulation, the collision front of circumannular activation shifted counterclockwise in contrast with the pattern observed during CS pacing. After ablation, circumannular activation was similar during CS and RV pacing, showing fully descending lateral right atrium activation, even if double potentials registered on the ablation line were less widely split during RV pacing than CS pacing (111±26 ms vs 128±30 , p=0.0001).

Conclusions

In patients with ventriculo-atrial conduction, tricuspid annulus activation during CS and RV pacing is similar, before and after CTI ablation. The occurrence of split atrial electrograms separated by an isoelectric interval registered on the line of block can be detected during CS or RV pacing. In patients with difficult CS catheterization via the femoral vein, before trying the subclavian or internal jugular route, if retrograde ventriculo-atrial conduction is present, RV pacing can be an easy trick to assess isthmus block.     

Kawasaki disease causing saccular aneurysms of the coronary arteries

A 22-year-old man was referred for treatment of a 45 mm saccular aneurysm of the right coronary artery (RCA) and a 15 mm saccular aneurysm of the left anterior descending artery (LAD). The patient developed Kawasaki disease in 1998. The aneurysms were diagnosed in 2002. The RCA showed thrombus formation. Until now the patient had remained asymptomatic. He now presented with effort angina. On coronary angiography and magnetic resonance imaging, an occluded aneurysm of the proximal RCA (45 mm) was seen with a second aneurysm more distally (22 mm).     

Anisocoria and middle cerebral artery saccular (berry) aneurysm in a rhesus macaque (Macaca mulatta)

A 27-year-old female rhesus macaque (Macaca mulatta) developed anisocoria. The left pupil was dilated and unresponsive to light. The macaque was euthanized because of unrelated reasons and the body was submitted for necropsy. On gross examination, a berry aneurysm of the right middle cerebral artery causing marked compression of the right optic tract was found. Arteriosclerotic changes were observed microscopically in the right middle cerebral and in the internal carotid arteries. The left iris was markedly degenerated, with atrophy of the constrictor muscle. Compression of the right optic tract may cause homonimus hemianopsia. A dilated and unresponsive left pupil indicated a lesion in the ipsilateral parasympathetic efferent pathway. In the absence of appreciable lesions of the left oculomotor nerve, the most likely cause of mydriasis was the iridic lesion. Intracranial aneurysms are common in humans (2 to 5%), but not in other species. Only about 10% of unruptured aneurysms are associated with neurologic deficits related to mechanical compression, such as visual deficits or anisocoria. Meticulous investigation of the ocular vascular and neural pathways led us to conclude that the anisocoria was unrelated to the aneurysm. To our knowledge, this report represents the first documented case of a naturally occurring intracranial aneurysm in nonhuman primates.     

INSERTION OF AN INTRAAORTIC BALLOON THROUGH A LIMB OF AN AORTOFEMORAL GRAFT AFTER AORTIC VALVE REPLACEMENT, DOUBLE CORONARY ARTERY BYPASS, AND RESECTION OF AN ABDOMINAL AORTIC ANEURYSM

This case report describes a useful and unusual route for insertion of an intraaortic balloon in 63-year-old man who was operated upon for calcific aortic stenosis, coronary atherosclerosis involving the left anterior descending and right coronary arteries, and a large abdominal aortic aneurysm. Aortic valve replacement was accomplished with a porcine heterograft prosthesis. Bypasses to the left anterior descending and right coronary arteries were constructed with reversed saphenous vein grafts, and the abdominal aneurysm was resected and repaired with a bifurcated woven Dacron vascular graft. An electively placed intraaortic balloon was inserted through the right limb of the aortic graft prosthesis and used to assist the patient during the immediate postoperative period. Uneventful recovery ensued.     

Percutaneous left ventricular partitioning device for chronic heart failure

We report the first implantation of a percutaneous left ventricular partitioning device in the Netherlands. This device is developed for patients with chronic heart failure due to a left ventricular apical aneurysm caused by an anterior myocardial infarction.     

Effect of atrio-ventricular conduction on the appearance of supraventricular arrhythmia and thrombotic complications in patients with chronic stimulation of cardiac ventricles in sick sinus syndrome]

Two hundred three patients with sick sinus node disease were treated with continuous ventricular stimulation between 1981 and 1985. To 1988, 168 patients aged between 26 and 88 years were followed-up for 5.1 years on the average. All these patients were divided into two groups: I (93 patients) with sinusal bradycardia, and group II (93 patients) with brady-tachycardia. Ventriculo-atrial conduction was seen in 82.61% of patients of group I in whom the implantation of electric stimulator produced the attacks of atrial fibrillation, and in 44.23% of patients without such attacks (p < 0.01); in 80.77% of patients of group II in whom atrial fibrillation became stable with time, and in 50.57% with intermittent atrial fibrillation (p < 0.01) ventriculo-atrial conduction was noted. It may be concluded, that the presence of ventriculo-atrial conduction in patients with prolonged stimulation of the cardiac ventricles favor the occurrence and stabilization of the paroxysmal atrial fibrillation and thrombotic complications.     

FALSE ANEURYSM OF THE LEFT VENTRICLE: CASE REPORT WITH PRE- AND POSTOPERATIVE EVALUATION

A 66-year-old woman developed chronic congestive heart failure after myocardial infarction of the anterior wall of the left ventricle. Angiographic studies revealed total proximal occlusion of the left anterior descending coronary artery and a large saccular aneurysm located on the anteroapical aspect of the left ventricle. Resection of a false aneurysm at operation resulted in improved cardiac function, and the patient made an uneventful recovery. Repeat evaluation six months later confirmed normal cardiac hemodynamics and left ventricular angiographic characteristics. To our knowledge, this is the first documented case of normalized heart function resulting from resection of a false aneurysm of the left ventricle. Functional classification according to the New York Heart Association improved dramatically, rising from Class IV preoperatively to Class I after operation.     

A New Murine Model of Endovascular Aortic Aneurysm Repair

Endovascular aneurysm exclusion is a validated technique to prevent aneurysm rupture. Long-term results highlight technique limitations and new aspects of Abdominal aortic aneurysm (AAA) pathophysiology. There is no abdominal aortic aneurysm endograft exclusion model cheap and reproducible, which would allow deep investigations of AAA before and after treatment. We hereby describe how to induce, and then to exclude with a covered coronary stentgraft an abdominal aortic aneurysm in a rat. The well known elastase induced AAA model was first reported in 1990¹ in a rat, then described in mice². Elastin degradation leads to dilation of the aorta with inflammatory infiltration of the abdominal wall and intra luminal thrombus, matching with human AAA. Endovascular exclusion with small covered stentgraft is then performed, excluding any interactions between circulating blood and the aneurysm thrombus. Appropriate exclusion and stentgraft patency is confirmed before euthanasia by an angiography thought the left carotid artery. Partial control of elastase diffusion makes aneurysm shape different for each animal. It is difficult to create an aneurysm, which will allow an appropriate length of aorta below the aneurysm for an easy stentgraft introduction, and with adequate proximal and distal neck to prevent endoleaks. Lots of failure can result to stentgraft introduction which sometimes lead to aorta tear with pain and troubles to stitch it, and endothelial damage with post op aorta thrombosis. Giving aspirin to rats before stentgraft implantation decreases failure rate without major hemorrhage. Clamping time activates neutrophils, endothelium and platelets, and may interfere with biological analysis.     

Mechanical Complications of Myocardial Infarction—Radiologic Aspects

Left ventricular aneurysm, interventricular septal defect and acute mitral valve incompetence due to papillary muscle damage are three mechanical complications which cause intractable heart failure following myocardial infarction. In each case surgical intervention can result in dramatic improvement of congestive heart failure.A hemodynamically significant left ventricular aneurysm enlarges the cardiac silhouette and frequently causes a localized protrusion as seen radiographically. Cardiac fluoroscopy will disclose an abnormal pulsation of the left ventricular border. The left ventricular angiogram establishes the diagnosis, reveals the extent of the aneurysm and may disclose a filling defect in the aneurysmal sac due to the presence of mural thrombus. Coronary arteriography shows occlusion of a major vessel, most commonly the anterior descending branch of the left coronary artery.Ischemic perforation of the interventricular septum and acute mitral incompetence due to severe papillary muscle damage both cause severe heart failure shortly after myocardial infarction. A similar pansystolic murmur accompanies both conditions, and differentiation between the two is rarely possible on the basis of the electrocardiogram or x-ray film of the chest. Ventricular cardiac catheterization and left ventricular angiocardiography are required for a correct diagnosis.     

SURGICAL MANAGEMENT OF DISSECTING ANEURYSM—The Use of a Simplified Bypass

The alarming mortality in cases of dissecting aneurysm of the aorta has stimulated the development of a surgical technique which results in re-entry of the dissecting channel. During the operative procedure prolonged cross-clamping of the aorta is necessary. While hypothermia will provide protection to the spinal cord and kidneys during reasonable periods of aortic occlusion it will not relieve back pressure on the left ventricle.By the use of a simple bypass blood is drained from the left atrium into a reservoir and then pumped into the lower aorta via the femoral artery. Thus an adequate supply of oxygenated blood is delivered to the spinal cord and kidneys distal to the occlusion while the left ventricular pressure is decompressed to normal levels. The volume of the shunted blood is simply controlled by monitoring the brachial artery pressure with a cuff sphygmomanometer. This simplified bypass has permitted successful repair of a dissecting aneurysm with complete occlusion of the thoracic aorta for a period of two hours.     

不同造影方法显示弹性酶诱导的兔囊状动脉瘤

目的评估经股动脉穿刺超选造影、静脉造影、心脏穿刺造影和左侧耳中央动脉穿刺造影方法显示弹性酶诱导的兔囊状动脉瘤的可行性。方法取10只新西兰兔,采用弹性酶诱导方法制作兔右侧颈总动脉起始部囊状动脉瘤模型。术后3周对所有动物分别进行经股动脉穿刺超选造影、静脉造影、心脏穿刺造影和左侧耳中央动脉穿刺造影,根据造影结果测量动脉瘤短径、长径和瘤颈宽。采用重复测量设计的方差分析方法比较不同造影方法显示的动脉瘤相关参数测量结果差异。结果采用经股动脉穿刺超选造影、静脉造影、心脏穿刺造影和左侧耳中央动脉穿刺造影方法均能较清楚的显示的动脉瘤,比较不同造影方法测量的动脉瘤短径、长径和瘤颈宽均无统计学差异（P值分别是0.646,0.427和0.625）。结论不同的造影方法均能较准确显示弹性酶诱导的兔囊状动脉瘤大小,根据不同的实验目的和条件可选用不同的造影方法。     

Anomalous origin of the left coronary artery: the effects of aortocoronary vein bypass on left ventricular function

The diagnosis, angiographic evaluation and surgical treatment by aortocoronary vein bypass are described in a 3½-year-old girl with anomalous origin of the left coronary artery from the pulmonary artery. The anomaly had resulted in cardiac dilatation, diminished left ventricular contractility, an aneurysm of the left ventricular free wall and mitral regurgitation.At the postoperative cardiac catheterization the graft was demonstrated to be patent, but a significant proportion of the flow to the left coronary artery was derived from anastomotic connections with the right coronary artery. The most striking evidence of improvement was obtained from the left ventricular volume studies which showed that the end systoiic volume had decreased from 85 to 49 ml./m.² with an increase in ejection fraction from 0.39 to 0.62, suggesting enhanced left ventricular contractility after surgery.The patient continues to do well and is free from symptoms.     

Quadricuspid pulmonary valve and left pulmonary artery aneurysm in an asymptomatic patient assessed by cardiovascular MRI

We present a coincidental finding of quadricuspid pulmonary valve and left pulmonary artery aneurysm. As both the pulmonary valve and the pulmonary trunk with its main branches are hard to visualise with cardiac ultrasound, most abnormalities described so far are from autopsy series. With the increasing use of CMR and its excellent potential for visualising both pulmonary valve and pulmonary arteries, we believe more cases will be discovered in the near future. Although pulmonary artery aneurysm are rare, timely detection may prevent lethal bleeding.