Right Ventricular Aneurysm Following Open Cardiotomy for Correction of Tetralogy of Fallot

Transcription

1 Right Ventricular Aneurysm Following Open Cardiotomy for Correction of Tetralogy of Fallot Juro Wada, M.D., Koji Ideda, M.D., Yutaka Kadowaki, M.D., and Shigeo Sugii, M.D. I n recent years, the development of extracorporeal circulation has facilitated the surgical treatment of ventricular aneurysm, and many successes have been reported. The majority of these reports have dealt with left ventricular aneurysms which developed following myocardial infarction. Aneurysms of the right ventricle by comparison are quite rare, only 14 having been previously reported (see Table 1). The following is a case report of right ventricular aneurysm which developed following open cardiotomy for correction of a congenital cardiac defect. A 14-year-old Japanese boy was admitted to the hospital for the first time on March 4, 1963, with complaints of palpitation, exertional fatigue, and frequent upper respiratory infections. He also showed cyanosis and digital clubbing. Since birth he had been thought to have congenital heart disease. Upon admission he was noted to have a low-pitched systolic murmur (Grade 2-6) heart! best in the third intercostal space along the left sternal border. Following right heart catheterization antl angiocardiography, a clinical diagnosis of tetralogy of Fallot was made. On April 28, 1963, total correction of the lesion, consisting of a closure of the ventricular septal defect with a Teflon patch and infundibulectomy, was carried out with the use of extracorporeal circulation. The postoperative course was uneventful, and the patient was discharged from the hospital 5 weeks after the operation without cyanosis even on exertion. Three months later he suffered from slight fever, palpitation, antl exertional fatigue. He was admitted again on December 6, 1963, when he was moderately cyanotic. There was a nonratliating systolic murmur (Grade 3-G) at the left sternal border in the third intercostal space associated with a systolic thrill. The blood pressure was 105/85 mm. Hg. A chest x-ray antl right angiocardiogram (Figs. 1, 2) revealed considerable protrusion of the pulmonic area compared with the films of the first admission. Right heart catheterization revealed a pressure of 8 mm. Hg (mean) in the right atrium, 80/0 in the right ventricle, and 20/0 in the pulmonary trunk. Oxygen saturation studies revealed a persistent shunt,. On the basis of these data, the clinical diagnosis of a persisting small yentricular septal defect and right ventricular aneurysm was made. From Department of Thoracic and Chrtlioi ascular Surgery, Sapporo hlctlical antl Hospital, Sapporo, Hokkaitlo, Japan. Receivcd for publication Aug. 26, College 184 THE ANNALS OF THORACIC SURGERY

2 CASE REPORT: Ventricular Aneurysm After liepair of Tetralogy FIG. 1. Chest x-ray showing protrusion of pulmonic area (second admission). FZG. 2. Right angiocardiogram at time of second ndmissioii. The patient was then operated upon, with extracorporeal circulation, on December 18, A median sternotomy was used to approach the aneurysm which measured 8 x 5 x 3 cm. It extended under the sternum and was adhcrent to its left lower portion. Following careful dissection of the aneurysm, cardiopulmonary bypass was started and the aneurysm was incised. Despite total drainage VOL. I, NO. 2, MAR.,

3 WADA, IDEDA, KADOWAKI, AND SUGII of both superior and inferior venae cavae, there was a large flow of saturated blood through the ventriculotomy. Examination revealed partial detachment of the previously placed patch. This was corrected with additional sutures, and the aneurysm was incised. Following the total removal of the aneurysm, the ventriculotomy margin was debrided and closed, using silk sutures (Fig. 3). FIG. 3. Schematic drawing of the right ventricular aneurysm and the repair of the aneu ysm. Examination of the aneurysm wall revealed components of both pericardium and epicardium but no myocardium. Actually this was a pseudoaneurysm of the right ventricle. The postoperative course was uneventful and there was complete clearing of the cyanosis. The patient was discharged 5 weeks after surgery. The chest x-ray upon discharge is shown in Figure 4. FIG. 4. Chest x-ray upon patient s discharge after removal of the aneurysm. DISCUSSION In 1954, from the study of autopsy cases, Schlichter et al. [I 13 reported a 20% postmortem incidence of ventricular aneurysm formation 186 THE ANNALS OF THORACIC SURGERY

4 ~~ CASE REPORT: Ventricular Aneurysm After Repair of Tetralogy following niyocardial infarction. This was attributed to weakness of the ventricular wall as a result of coronary occlusion. Sternberg [14] reported a ventricular aneurysm rate of 84.1% (174) in 207 myocardial infarctions. Fulton [5] noted in his paper that aneurysms were found in almost all his cases which showed ischmic damage of the ventricular wall following coronary atherosclerosis. He concluded that as a result of ischemic softening following coronary occlusion the wall might not tolerate any sudden rise in ventricular pressure, and the result would be aneurysm formation. Other etiologic factors are trauma, syphilitic involvement, and endocarditis of rheumatic origin. Sutton and Davis [15] in experiments observed ventricular aneurysms developing after forced exercise in dogs which had been subjected to experimental coronary occlusion. Schlichter et al. [I 11, in their 102 clinical cases of aneurysm, concluded that over two-thirds of their patients had not taken enough rest after sustaining coronary occlusion. They also stated that 27 of the total 102 cases also had valvular insufficiency which made it difficult to obtain functional cardiac rest because of the high pressure during diastole due to regurgitation from insufficient valves. Reporter TAB1.E 1. REPORTS OF RIGHT VENTRICULAR ANEIJRYSMS FOUND IN THE LITERATURE No. Cases Autopsy Serics Hall (1903) 1 Appelbaum & Nicholson (1935) 1 Legg (quoted by Perkinson [19581) 1 Stirgiro1 Serirs Sauerbruch (1931) 1 Campbell (1954) 1 McCord & Rlount (1955) I Dubost (1955) Spacek et al. (1959) Derra & Loogen (1 959) Wada et al. (19GO) Fatti (quoted by Kerr [19611) 1 Kerr (1961) Stansel (1961) Wada et al. (1960) Total 14 Comment Found in 112 ventricular aneurysms at autopsy Found in 56 ventricular aneurysms at autopsy Found in 90 ventricular aneurysms at autopsy E t io lo<gy Unknown Infundibulectomy for tetralogy of Fallot Pulmonary valvotomy Constrictive pericarditis and mitral insufficiency Brock s procedure for tetralogy of Fallot Trauma Total correction of tetralogy of Fallot VOI,. 1, NO. 2. MAR.,

5 WADA, IDEDA, KADOWAKI, AND SUGII In contrast, right ventricular aneurysm is rare; 14 cases in the literature are summarized in Table 1. The first clinical case was not reported until 1931 when Sauerbruch [lo] operated on one which had been diagnosed as a mediastinal tumor. The majority of the subsequently reported cases, including our present case, have followed cardiotomy for correction of the tetralogy of Fallot. Stansel et d. [13] listed the etiological factors in ventricular aneurysm as follows: (1) necrosis of the ventricular wall, (2) trauma, and (3) ventriculotomy. Upon analysis of the etiology of the reported cases of right ventricular aneurysm (see Table l), it is seen that 8 occurred in patients with tetralogy of Fallot who had undergone corrective surgery. It is interesting to note the greater frequency of aneurysm following surgical procedure for tetralogy of Fallot than for ventricular septal defect alone. The case reported here also belongs in this category. Because of the lack of details regarding surgical technique in the literature, it is difficult to analyze the cause of aneurysm following total correction of the lesion. However, it is clear from a review of the literature and from our own experiments that there are higher right ventricular pressures and better-developed coronary arteries in cases of tetralogy of Fallot. This may account for the high incidence of right ventricular aneurysm after right cardiotomy for this condition. SUMMARY A 14-year-old boy was found to have developed an aneurysm of the right ventricle seven months after having a definitive repair of a tetralogy of Fallot. When repair of the aneurysm was carried out he was also found to have had some reopening of the ventricular septal defect due to partial detachment of the patch. The aneurysm was excised, the patch over the septal defect was resutured, and the ventriculotomy closed. His subsequent course was uneventful. The various causes of ventricular aneurysm have been discussed. REFERENCES 1. Appelbaum, E., and Nicholson, G. H. G. Occlusive disease of the coronary arteries: An analysis of the pathological anatomy in 168 cases with electrocardiographic correlation in 36 of these. Amer. Heart,I. 10:662, Campbell, M., Deuchar, D. C., and Brock, R. Results of pulmonary valvulotomy and infundibular resection in 100 cases of Fallot s tetralogy. Brit. Med. J. 2:111, Derra, E., and Loogen, F. On ventricular aneurysm or diverticulum and its surgical treatment. Deutsch. Med. Wschr. 84: 1585, Dubost, C. In C. Lam (Ed.), Cnrdiovnsczrlnr Surgery (Henry Ford Hospital International Symposium). Philadelphia: W. B. Saunders, 1955, p Fulton, M. N. Aneurysm of the ventricle of the heart. J.A.M.A. 116:115J THE ANNALS OF THORACIC SURGERY

6 CASE REPORT: Ventricular Aneurysm After Repair of Tetralogy 6. Hall, D. G. Cardiac aneurysm. Edinburgh Med. J. 14:346, Kerr, W. F., Wilcken, D. E. L., and Steiner, R. E. Jncisional aneurysm of the left ventricle. Brit. Heart J. 23:88, McCord, M. D., and Blount, S. G. Complications following infundibular resection of Fallot s tetralogy. Circulation 11:754, Perkinson, J., Bedford, D. E., and Thomson, W. A. R. Cardiac aneurysm. Quart. J. Med. 7:455, Sauerbruch, F. Erforgreiche operative resektionung eines Aneurysma der rechten Herzkammer. Arch. Klin. 167:586, Schlichter, J., Hellerstein, H. K., and Katz, L. W. Aneurysm of the heart. Medicine 33:43, Spacek, B., Bergman, D., and Dejdar, R. Uber die Resektion eines falschen Herzwandaneurysmas. Zbl. Chir. 84:689, Stansel, H. C., Jr., Julian, 0. C., and Dye, W. S. Right ventricular aneurysm. J. Thorac. Cardiov. Surg. 46:66, Sternberg, M. Das Chronische Partielle Herzaneurysm. Vienna: Franz Deutlicke, 1914, p Sutton, D. C., and Davis, M. D. Effects of exercise on experimental cardiac infarction. Arch. Intern. Med. 64:493, Wada, J., Nakase, A., Ogasawara, H., and Shibuya, Y. Successful excision of the right ventricular aneurysm. Operation (Shujutsu, Japan) 14: 1621, VOL. I, NO. 2, MAR.,