PMC6023718_01
(
A
) occluded circumflex artery (LAO 20/CAU 20) (*). (
B
) Levocardiography showing the pseudoaneurysm after the free left ventricular wall rupture (#).
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Ventriculography showed preserved systolic function of the left ventricle (LV) and a very weak and blurred contrast near to the lateral left ventricular wall ( Fig. 1 ), and hemoglobin levels had quickly dropped to 5.4 g/dL according to blood gas analyses acquired during the catheterization procedure.
(
A
) Computed tomography (CT) showing the pseudoaneurysm after left ventricular rupture and a large hematothorax. (
B
) CT after successful reconstruction of the left ventricle.
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CT of thorax and abdomen was performed. CT showed no signs of pulmonary embolism and aortic dissection but confirmed rupture of the LV with a pseudoaneurysm of the LV and an associated large left-sided hematothorax ( Fig. 2 ). 
The two felt pledgets covering the entry at the site just in line with the occluded circumflex artery. Later, additional two felt pledgets were sutured at the second entry site (#).
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To spare the left ventricular wall and to avoid a large modified Dor plasty, we isolated both entries using two felt pledgets, each connected with running sutures ( Fig. 3 ).
(
A
) Scheme of used reconstruction method. Two large felt pledgets (#) are sutured around the entry sites (*) of the pseudoaneurysm. (
B
) After the reconstruction, the entries are closed by the running suture. Additional BioGlue is used to attach a large pericardial patch (+) on the outside to minimize bleeding. LV, left ventricle; RV, right ventricle.
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After successful closure of both entries, we used a 4 x 4 cm large bovine pericardial patch and BioGlue (Cryolife; without additional sutures) to prevent further bleeding ( Fig. 4 ).  Postoperative transthoracic echocardiography showed a left ventricular ejection fraction of 25% with competent valves ( Fig. 4 ). 