Rock at the LVAD Core: Inadvertent Calcified Apical Aneurysm during LVAD Implantation

Abstract

Introduction Patients with ischemic cardiomyopathy (ICMP) and advanced CHF are at risk to develop calcified ventricular aneurysms as part of their ischemic remodeling over time. These aneurysms can significantly interfere with left ventricular assist device (LVAD) implantation. We present a case of a patient who had a calcified apical aneurysm that was preoperatively missed and inadvertently discovered during his LVAD surgery. Case A 70 year-old male with a medical history of ICMP (EF 5-10%, NYHA II, Stage D) status post ICD placement on the heart transplant waiting list, CAD status post CABG (11 years ago), and a-fib presented for an elective LVAD implantation as a bridge to transplant due to worsening in his kidney function and declining in his myocardial oxygen consumption. The patient had CXR and TTE before his planned surgery as part of preoperative work up. During the operation, a calcified apical aneurysm was discovered and resected (figure 1). Afterward, the LVAD swing ring was fixed to the LV apical ventriculotomy followed by the LVAD inflow graft insertion. Thereafter, the operation was completed as planned. The patient recovered and was eventually discharged home. Discussion Pre-LVAD identification of any calcified myocardial aneurysm is important especially when it is apical as the LVAD inflow graft cannot be sutured over calcified myocardial tissue. In our patient, CXR and TTE failed to identify his calcified apical aneurysm before surgery. Fortunately, the size of his calcified aneurysm was not very big and the surgeon was able to appropriately fix the LVAD swing ring on LV apical ventriculotomy after resecting the aneurysm. Retrospectively, our patient's long history of ICMP, very low cardiac function, and dilated LV (end-diastolic diameter of 7.4 cm) were all unnoticed hints toward possible calcified aneurysmal formation that would have been discovered with advanced imaging modalities such as computed tomography (CT) of the chest. Conclusion Calcified apical aneurysms can develop in patients with ICMP and advanced CHF and should always be looked for before LVAD implantation. Advanced imaging techniques, such as CT of the chest, can help to identify such calcified aneurysms preoperatively and safely tailor surgical plans in these patients.