Repair of Iatrogenic RVOT Pseudoaneurysm

The authors present a video case report of an ex-premature, corrected age of 35 weeks who was referred because of a large patent ductus arteriosus, heart failure, and failure to thrive. After multiple unsuccessful attempts at patent ductus arteriosus device closure, it spontaneously closed. At some point during the procedure, the catheter wire was noted to have potentially caused inadvertent injury to the right ventricular outflow tract. The child returned to the intensive care unit stable and was followed up with serial echocardiograms.

A follow-up echocardiogram two weeks later showed a multilobed right ventricular pseudoaneurysm, measuring at its mouth 11 millimeters. To-fro flow was seen without any thrombus formation and a mild to moderate pericardial effusion. This was confirmed with CT.

The patient was taken to the operating room weighing 2.9 kilograms. After median sternotomy, the pericardium was incised except the part overlaying the pseudoaneurysm, which was left untouched until satisfactory cannulation was achieved.

Bypass was initiated with aortic and inferior vena cava cannulation. The pseudoaneurysm was closely inspected, paying significant attention to its proximity to the left anterior descending coronary artery (LAD). The superior vena cava was cannulated, the aorta was clamped, antegrade cardioplegia was started, and the patient was cooled to a rectal temperature of 32°C. The right atrium was incised and the left heart vented through the patent foramen ovale (PFO). The authors chose to do the repair under cardiac arrest given the close proximity to the LAD. The pseudoaneurysm was inspected again and excised to its fibrous rim. The pulmonary valve was inspected and a patch of Cardiocel neopericardium was prepared. A running suture with 6-0 polypropylene was started on the most lateral edge closest to the LAD. The fibrous rim was considered strong enough to hold the bites from the suture, which was continued superiorly. Care was taken not to damage the pulmonary valve or LAD. The patch was trimmed to its appropriate size.

The suture line was tied and the final result inspected. A series of 6-0 polypropylene horizontal mattress sutures were placed to reinforce and prevent recurrence.

The heart was de-aired and the aortic clamp removed. The PFO was closed primarily followed by the atriotomy closure and intracardiac line placement. The patch area was covered with hemostatic glue and the chest closed.

Postoperative recovery was uneventful and the discharge echocardiogram showed no residual pseudoaneurysm, mildly reduced right ventricular systolic function, normal left ventricular systolic function, and a normal pulmonary valve with physiologic insufficiency. The patient remains well without recurrence on echocardiogram two months after surgery.

Reference

Rato J, Ataíde R, Teixeira A. Giant pseudo-aneurysm of the right ventricular outflow tract after Tetralogy of Fallot repair. Cardiol Young. 2020 Sep;30(9):1332-1334.