Technique
A healthy 57-year-old female was evaluated for frequent episodes of
atypical chest pain, which revealed a CLVD. She had no history of
myocardial infarctions, mediastinal infections, or trauma. A computed
tomography angiography demonstrated an anterolateral left ventricular
outpouching measuring 4.9 x 3.8 x 1.6 cm, accompanied by a narrow neck
with areas of thick and thin wall containing trabeculations. A cardiac
magnetic resonance imaging study confirmed similar dimensions and noted
the walls to be thinned in focal regions (Fig 2). Coronary angiogram
showed normal coronary arteries.
Intraoperative transesophageal echocardiogram showed blood flow into the
CLVD. Through a median sternotomy, the patient was placed on
cardiopulmonary bypass with ascending aortic arterial and right atrial
venous cannulation. The heart was arrested and the left ventricle
inspected. A 5 x 4 cm area of protrusion with thinned myocardium was
noted on the anterolateral aspect of the left ventricle (Fig 1A). The
thinned area of tissue was opened through a 5 cm linear incision (Fig
1B). The discrete neck communicating with the left ventricular wall
measured 3 cm, allowing flow between the CLVD and the left ventricle.
Multiple pledgeted 4-0 polypropylene horizontal mattress sutures were
passed from outside-to-in through the rim of healthy appearing
myocardium just above and around the diverticular neck. These were then
each passed through the perimeter of a circular 6 x 4 cmHemashield (Maquet Holding, Rastatt, Germany) patch that laid on
top and flush with the diverticular neck, and subsequently tied (Fig
1C). Care was taken to inspect and avoid the subvalvular mitral
apparatus. The patch sealed off the CLVD from the left ventricular
cavity while avoiding compromising the true ventricular lumen (Fig 1D),
its geometry, or reducing the intraventricular volume.
A second set of pledgeted 4-0 polypropylene sutures were placed from
inside the CLVD in a horizontal mattress fashion, circumferentially
around the linear incision through the wall of the diverticulum. These
sutures were taken more proximal to the epicardial surface, above the
level of the first patch placed near the diverticular neck, encircling
the incision into the diverticulum (Fig 1E). The incision into the
cavity was then oversewn with two running 4-0 polypropylene sutures,
with a pledget on either side of the incision, ensuring appropriate
approximation, but with care to apply minimal tension to either free
edge, limiting how tightly they were brought together (Fig 1F).
A second circular Hemashield patch 7 cm in diameter was then
fashioned. Half of the adjacent epicardial mattress sutures were then
passed through this patch. The patch was subsequently lowered and these
adjacent sutures were securely tied, leading to half the patch being
secured to the surface of the epicardium. BioGlue (CryoLife Inc,
Georgia, United States) was applied to this pocket of space between the
epicardium and the Hemashield patch, with the other half of the
remaining adjacent sutures then passed through the patch and tied
securely once the glue had been allowed to settle (Fig 1G).
The cross clamp was removed and the patient weaned off bypass.
Transesophageal echocardiogram showed good biventricular function
without a compromise in ventricular lumen, with no communication, and
complete exclusion of the diverticular cavity. Her post-operative course
was uneventful.