PMC9445196_01
Preoperative echocardiography and computed tomography results. Anterior tricuspid leaflet prolapse was observed by TTE (red arrow; A). Tricuspid prolapse resulted in moderate tricuspid regurgitation (B). TTE revealed avulsion of anterior tricuspid leaflet resulting in moderate tricuspid regurgitation, a 23 mm x 38 mm giant aneurysm with a 19-mm diameter of the neck in the LVPW (red arrow; C) and visible blood flow into the aneurysm (D). CT scan and reconstruction confirmed a massive ventricular aneurysm in the LVPW (red arrow; E,F). TTE, Transthoracic Echocardiography; LVPW, left ventricular posterior wall; CT, computed tomography.
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Using transthoracic echocardiography (TTE), anterior tricuspid leaflet prolapse was observed because it is the first-line diagnostic tool for evaluating the tricuspid valve (Figure 1A). This tricuspid prolapse resulted in moderate tricuspid regurgitation (Figure 1B). TTE revealed avulsion of anterior tricuspid leaflet resulting in moderate tricuspid regurgitation, a 23 x 38 mm giant aneurysm with a 19-mm diameter of the neck in the left ventricular posterior wall (LVPW) (Figure 1C), and visible blood flow into the aneurysm (Figure 1D). Computed tomography (CT) scan and reconstruction confirmed a massive ventricular aneurysm in LVPW (Figures 1E,F). The sketch of ventricular aneurysmorrhaphy and tricuspid valvuloplasty was provided (Supplementary Figures S1, S2).
Surgical procedure. The aneurysmal portion of the left ventricle was thinned and was significantly expansive, the aneurysm well has sharply defined edges (blue arrow; A). The bovine pericardium was used to close the aneurysm's neck after being surgically incised (B,C). Felt pads were used to close the epicardium over the patch (D), resulting in a detour formed around the posterior descending artery (PDA) and PDA was well protected in a "sandwich" (green arrow; E,F). The third strip of the felt pad reinforced the "sandwich" structure (blue arrow; F). 5.0 Prolene suture lines were used to sew the rupture, valvuloplasty of the anterior tricuspid leaflet was performed (G,H). Testing with saline solution injection showed no tricuspid regurgitation (green arrow; I). PDA: the posterior descending artery.
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During surgery, after sternotomy and the pericardium being incised, we found that the aneurysmal portion of the left ventricle was thinned and was greatly expanded (Figure 2A), and there was no pericardial adhesion. The myocardial layers were continuous, the aneurysm well had sharply defined edges (Figure 2A). After being surgically incised, the bovine pericardium was used to close the aneurysm's neck (Figures 2B,C). Felt pads were then employed to close the epicardium over the patch (Figure 2D), resulting in a detour formed around the posterior descending artery (Figures 2E,F). The third strip of the felt pad reinforced the "sandwich" structure (Figure 2F). A right atriotomy was performed to repair the anterior leaflet of the tricuspid valves with a 5 mm tear. 5.0 Prolene suture lines were utilized to sew the rupture, and valvuloplasty of the anterior tricuspid leaflet was performed (Figures 2G-I). 5.0 Prolene suture was used to figure-of-eight suture on the junction between the anterior annulus and the posterior annulus, and the junction between posterior annulus and septum annulus. Testing with saline solution injection and intraoperative esophageal echocardiography showed no tricuspid regurgitation (Figures 2I, 3A) and revealed no residual shunt for LVPW (Figure 3B). The sketch of ventricular aneurysmorrhaphy and tricuspid valvuloplasty was provided (Supplementary Figures S1, S2).
Follow-up. It showed no tricuspid regurgitation by intraoperative esophageal echocardiography showed no tricuspid regurgitation (A) and revealed no residual shunt for LVPW (B). The postoperative CT scan and reconstruction revealed successful surgery (C,D). LVPW, left ventricular posterior wall; CT, computed tomography.
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Testing with saline solution injection and intraoperative esophageal echocardiography showed no tricuspid regurgitation (Figures 2I, 3A) and revealed no residual shunt for LVPW (Figure 3B). The postoperative CT scan and reconstruction revealed successful surgery (Figures 3C,D).
Histological examination. Histological examination revealed massive fibrous tissue in the aneurysm wall (Figure x200).
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Histological examination demonstrated massive fibrous tissue in the aneurysm wall,myocardial fiber disappears is replaced by hyperplained fibrous tissue, fibrous connective tissue increases, and glass -like changes in local fiber tissue (uniform consistency, no structure and translucent protein accumulation) (Figure 4, x200), consistent with trauma-induced aneurysms.