Penetrating Giant Pseudoaneurysm of the Left Ventricle Complicating a Combined Heart-Liver Transplant

Abstract

<h3>Introduction</h3> Left ventricular pseudoaneurysms (LV PsA) pose significant mortality risk and a paucity of data to guide management. We present a case of a giant LV PsA and its unique challenges to advanced options evaluation. <h3>Case Report</h3> A 58-year-old man with a history of heart failure (HF) with reduced ejection fraction, ischemic cardiomyopathy, 3-vessel coronary artery bypass grafting, inferior LV aneurysm repair with a Dacron patch, and hepatic cirrhosis presented for advanced options evaluation given worsening HF symptoms. His course was complicated by 3 prior sternotomies for 1) a mitral valve (MV) repair; 2) a MV and tricuspid valve replacement (TVR) with a Dor-type reconstruction and bovine patch repair of a persistent LV aneurysm, 14 years prior; and 3) a mediastinal abscess exploration with redo TVR/aneurysm repair, 6 years prior. Transthoracic echocardiography showed severely reduced LV performance and a large 1.7-cm defect in the basal-mid inferior wall with to and fro flow concerning for a very large PsA (Fig. A). Computed tomographic angiography of the heart confirmed a gigantic PsA herniating through the diaphragm (Fig. B). Right heart catheterization showed elevated biventricular pressures with low cardiac output. Due to the severity of the LV PsA, the patient was deemed not to be a candidate for implantation of a durable left-ventricular assist device and was listed for dual heart-liver transplant. During the surgery, the LV PsA was noted to have invaded through the diaphragm and into the inferior vena cava and left pleural space from which it was carefully resected and the diaphragm closed (Fig. C). The patient tolerated the procedure and continues to do well 3 months after transplantation. <h3>Summary</h3> Giant LV PsA is a rare but serious complication of ischemic disease and prior cardiac surgeries that can drastically alter the advanced management of end-stage HF. Careful evaluation with multi-modality imaging is essential to procedural success.