A case of idiopathic sub- annular outpouchings in LVOT: Emphasizing the importance of comprehensive intraoperative TEE examination in cardiac surgery

Viruksha, Balakrishnan N, G Pravin kumar*, Murshid ahamed

Department of Cardiac Anaesthesia, Kauvery Hospital, Heart city, Trichy

Introduction

Left ventricular outflow tract outpouching is rare and uncommon condition. While, it may appear clinically insignificant at first, it carries the risk of serious and potentially fatal complications. This type of outpouchings is most often seen in patients with history of cardiac surgery, myocardial infection, prosthetic aortic valve replacement, infective endocarditis, chest trauma or congenital cardiac abnormalities. [2] Clinical presentations are usually nonspecific, but problems arise when the cul-de sac compress nearby structures such as LVOT, coronary artery, pulmonary artery, left atrium, or left main bronchus. A rupture into these neighbouring areas can be catastrophic and often fatal. Hereby, this case highlights the pivotal role of TEE in establishing the diagnosis.

Case Presentation

A 52 years old female, known hypertensive, was diagnosed to have tricuspid aortic valve, calcified with severe aortic regurgitation, with dilatation of both left atrium and left ventrice with reduced EF of 35%. The patient was scheduled for elective Aortic valve replacement. Preoperative coronary angiogram revealed no significant coronary artery disease. On the day of the surgery induction was done according to institutional protocol. Intraoperative 4 transesophageal echocardiogram revealed a cul-de sac which was originating from LVOT near NCC and LCC. (Fig 1,2,3). Native aortic valve was replaced with 21mmFlomero bioprosthetic valve and the out-pouchings were obliterated from the LV side with autologous pericardial patch below NCC and another below LCC with 5-0 prolene continuous sutures. Bypass time was 80 min and cross clamp time was 40 min. Patient was weaned from cardiopulmonary bypass with dopamine 10mcg/kg/min, adrenaline 0.1mcg/kg/min. After gradual weaning from inotropes and ensuring minimal mediastinal bleeding, trachea was extubated after 12 hr. Rest of the post operative recovery of the patient was uneventful. The excised valve was sent for culture and was sterile. Histopathological examination was consistent with rheumatic origin. Post CPB TEE demonstrated normal functioning of prosthesis with intact pericardial patch. [Fig 4]

Fig (1): 2D AV sax view demonstrating non coapting AV calcified with two Cul-De Sacs near NCC and LCC – Pre-CPB

Fig (2): ME LAX view demonstrating a cul-de-sac originating from LVOT- PRECPB

Fig (3): 2D DTG view demonstrating an out-pouching originating from LVOT- PRECPB

Fig (4): Immediate Post CPB – 2DME LAX view demonstarting intact pericardial patch in LVOT

Discussion

LVOT outpouching is a rare clinical entity and its clinical features also not predictable. [1] Our patient did not have any coronary artery disease, connective tissue disorder or infective endocarditis features. Literature search did not show any article mentioning LVOT outpouching without any predisposing factor. Various case reports have mentioned it after history of infective endocarditis, myocardial infection, chest trauma, cardiac surgery, prosthetic aortic valve implantation. [2] Our patient did not have any predisposing causative factor. Other Differential diagnosis of hematoma and abscess were ruled out intraoperatively since there was no smoky appearance or purulent discharge. Diagnosis of LVOT outpouching using echocardiography can be challenging, as other pathological condition may also present as echo free regions around the left atrium such as pericardial fluid, atrial wall dissection or cysts. A pseudo aneursym typically has a narrow neck compared to its sac, where as a true aneurysm has neck diameter that is almost equal to the body of the lesion. Traditionally these have been treated surgically, however transcatheter occlusion with coils or devices can be safely performed with good success [3]. Intra-opertaive transesophgeal echocardiography (TEE) was crucial in presciely identifying the cul-de sac, guiding the surgeon in management and saving the patient from complication like mechanical compression, sudden rupture leading to cardiac tampanode or thromboembolic events.

Conclusion

A thorough pre and post CPB TEE examination is always required. Our patient did not have the any predisposing conditions. Intraoperative trans-esophageal echocardiography had helped in diagnosis and guided the surgical team in managing this case with autologous pericardial patch, missing that would have resulted in fatal post operative complications.

References

  • Hulten EA, Blankstein R. Pseudoaneurysms of the heart. Circulation. 2012; 125:1920–1925.
  • Yeo T, Malouf J, Reeder G, Oh JK. Clinical characteristics and outcome in post infarction pseudoaneurysm. Am J Cardiol. 1999; 84:592–595.
  • Hurwitz, S. Shipton, C. Seaman, Transcatheter Occlusion of a Left Ventricular Outflow Tract Pseudoaneurysm with Penumbra Embolisation Coils, Heart, Lung and Circulation, . 2024;33-4-5

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