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J Thorac Cardiovasc Surg 2005;129:1175-1177
© 2005 The American Association for Thoracic Surgery
Brief Communications |
a Department of Cardiovascular and Thoracic Surgery, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Thiruvananthapuram, Kerala, India
b Department of Cardiology, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Thiruvananthapuram, Kerala, India.
Received for publication May 23, 2004; revisions received July 31, 2004; accepted for publication August 27, 2004. * Address for reprints: Soman Rema Krishna Manohar, MCh, Department of Cardiovascular and Thoracic Surgery, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Thiruvananthapuram, Kerala 695011, India (E-mail: manohar{at}sctimst.ker.nic.in).
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Submitral left ventricular aneurysms are rare forms of nonischemic aneurysm thought to be developmental in origin. Originally described in young male subjects of African ancestry,1 they occur in relation to the posterior mitral annulus, producing valve incompetence and left ventricular dysfunction. The widespread availability of echocardiography in recent years has made preoperative diagnosis possible.2 We focus on our experience with the surgical correction of this uncommon entity.
Patients and methods
Demographic and preoperative variables are summarized in Table 1.
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Operative technique
Table 1 summarizes the operative approach and outcome. Standard aortic and bicaval cannulation was used for cardiopulmonary bypass in 6 patients. Femoral cannulation was used for bypass in 2 patients who underwent thoracotomy.
In 5 patients we approached the aneurysm through the left atrium after incising the floor.3 Unfortunately, the aneurysm did not extend superiorly and hence remained inaccessible. In 3 patients we attempted to access the neck after complete mitral valve excision, this despite the fact that the valves were relatively normal. The valves unfortunately required replacement. The aneurysm was repaired in 2 patients but could not be accomplished in 1 patient, despite valve excision, and the valve alone was replaced. In the fifth and sixth patients the aneurysm remained inaccessible from the left atrial floor and hence was approached externally and repaired.
We approached the aneurysm through a thoracotomy in 2 patients. The first had mild mitral regurgitation, the aneurysm was approached easily, and the mouth was closed directly. The circumflex coronary artery seen coursing along the superior margin of the aneurysmal neck could easily be protected. The second patient had severe mitral regurgitation. The aneurysm originated from the posterior left ventricular wall in relation to the crux and lay on either side of the circumflex coronary. Although the vessel was easily visualized, we did not repair the part of the aneurysm lying superior to the circumflex coronary artery to avoid sacrificing this artery in a young patient.
Outcome
Three patients are undergoing long-term follow up. The first, followed for 15 years, has remained asymptomatic. The 2 remaining patients underwent aneurysm repair through a thoracotomy. Of these, one remains asymptomatic over the last 7 years with mild mitral regurgitation, and the other, in whom a combined approach was used, has been asymptomatic for 3 years with a small residual aneurysm.
Discussion
Submitral left ventricular aneurysms are usually found singly in the submitral position. The circumflex coronary artery generally lies in relation to the posteroinferior aspect of its neck (Figure 1, A). Coronary artery compression can occur and contributes to left ventricular dysfunction. The direction of growth is variable4 but occurs predominantly behind the left atrium. Factors that dictate this are largely unknown, but the atrioventricular valve and the circumflex coronary artery probably make a good guide.
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Coronary angiograms with left ventricular injections can demonstrate the relation of the aneurysm to the circumflex coronary artery and the direction of its growth (Figure 2). In our patients the aneurysm extended posteroinferiorly, with the circumflex coronary artery lying in relation to the superior aspect of its neck in all (Figure 1, B). Although this appears to be only a minor variation, it has a major influence on surgical approach. The left atrial approach in this setting would not only be unsuccessful in providing access to the neck, but this could also jeopardize the circumflex coronary artery if attempted. In those in whom this approach was attempted, we accessed the neck with difficulty and after mitral valve excision. This presentation could also explain the less common mitral involvement. In aneurysms enlarging superiorly above the circumflex, a transatrial approach would no doubt be ideal. In cases similar to ours, a direct approach through a left thoracotomy is a good alternative because the circumflex artery can be clearly visualized and protected. Moreover, most patients do not have significant mitral regurgitation and might not require an additional mitral valve procedure.
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References
This article has been cited by other articles:
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  C. Sai Krishna, P. V. N. Kumar, N. K. Panigrahi, and K. Suman Submitral aneurysm with left atrial communication Eur J Cardiothorac Surg, September 1, 2007; 32(3): 547 - 549. [Abstract] [Full Text] [PDF]
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