Left Ventricular Outflow Tract Aneurysm Compressing the Left Main

Left ventricular outflow tract aneurysm compressing the left main. A 44 –year-old male patient presented with shortness of breath and chest pain. ECG showed ST depression in the lateral leads. Echocardiogram showed subaortic aneurysm below the left coronary and non-coronary cusp with impaired LV function. Left coronary angiogram revealed 90% obstruction of Left Main due to dynamic compression by LVOT aneurysm. CT shows the bulge of the aneurysm with compression of Left Main. Cardiopulmonary bypass was established with ascending aorta and right atrial cannulation. Right superior pulmonary vein vent inserted. Aorta was cross clamped. Aortic root cardioplegia given. Aorta was separated from the pulmonary artery. You can see the aneurysm medially posterior to the aorta and laterally between the pulmonary artery and lateral wall of LV. Aortotomy was done. Aneurysmal sac was seen below the left coronary cusp and you can see the sac filled with clots. To increase the exposure, aorta was transected, after which it became easier to analyze the anatomy and do the correction. 4-0 pledgetted prolene sutures were taken all around the edges of the aneurysm. We took stitches carefully to avoid distortion of the left coronary cuspal attachment to the anulus. A piece of bovine pericardium was used to close the aneurysmal defect. Patch was then pushed down in the aorta and sutures were tied off.

After placement of patch, aortic valve was inspected and competency checked. Aortotomy was closed in a routine fashion. Since the patient had compression of left main, even though it was dynamic compression, we thought it will be safer to put a vein graft to left anterior descending artery. We didn't want to use IMA because of the fear of competitive flow. Patient was weaned off bypass easily. He was discharged on POD-6. CT angiogram after 2 years revealed patent vein graft with obliteration of aneurysmal cavity.

Reference(s)

1) Unusual Cause of Angina: Dynamic Left Main Coronary Artery Compression by Left Ventricular Outflow Pseudo-Aneurysm
Anas Alani, John Brandt, George Arnaoutakis, Michael Massoomi, and John Petersen

2) Acute Coronary Syndrome Resulting from Systolic Compression of Left Main Coronary Artery Secondary to Aortic Subvalvular Aneurysm
Partha Sardar, MD, Evbu Enakpene, MD, James C. Fang, MD, Frederick G.P. Welt, MD