Minimally invasive surgery via bilateral thoracotomy for treating left ventricular aneurysm with concomitant ventricular septal rupture
Left ventricular aneurysm (LVA) with concomitant ventricular septal rupture (VSR) can be a fatal sequela of myocardial infarction (MI) . Full median sternotomy is a common treatment for this lesion. However, full sternotomy has negative effects on breathing and exercise thoracic stability, which may increase the surgical risk in older or fragile patients . Herein, we report a successful minimally invasive surgery via bilateral thoracotomy for the treatment of a fragile older patient with LVA and VSR. 

A 79-year-old male patient weighing 65 kg visited a local hospital complaining of sudden-onset chest pain for 16 h. A diagnosis of acute MI was confirmed by electrocardiography and high-sensitivity troponin test. Angiography revealed complete obstruction at the origin of the left anterior descending coronary artery (LAD), with 20–30% stenosis of the left circumflex artery and right coronary arteries. A coronary stent was implanted to restore blood flow to the LAD. The patient was discharged 1 week later. Regular oral therapies, such as antiplatelet drugs and statins, were administered. However, the patient developed progressive heart failure 21 days after discharge. Echocardiography showed a LVA (34.7 mm × 44.4 mm) and a VSR of 10 mm close to the apex [Figure , ]. The patient had a history of hypertension for 15 years, diabetes for 8 years, and chronic obstructive pulmonary disease for 5 years. Considering the high surgical risk (STS score was 15.5%), we planned to perform bilateral thoracotomy for the LVA and VSR. 

General anesthesia was induced and a double-lumen endotracheal tube was placed with the patient in the supine position. Extracorporeal circulatory cannulation was performed through the right femoral artery and veins. A 3 cm incision was made in the right 3rd intercostal space to insert the aortic root and left atrial vent cannula, then a 7 cm incision was made in the left 6th intercostal space to expose the apex. Adhesions were observed when the pericardium was opened. After carefully separating the adhesions, an obvious scar and reverse motion were found on the anterior wall of left ventricle. Aortic clamping was performed via the right incision when the temperature dropped to 32℃, followed with antegrade 1:4 cold blood cardioplegia perfusion. The ventricular wall was incised. Obvious fibrosis was found at the ventricular wall of the LVA and the ventricular septum around the VSR. A polyester fabric patch was used to close the VSR using running sutures. The left ventricular wall was closed with three interrupted sutures using two felt pledgets mattress (6 cm in length) on each side of the LVA. Then, the aortic clamp was removed. Extracorporeal circulation was weaned off when the hemodynamics were stable. The aortic clamping, cardiac pulmonary bypass, and operative times were 33 min, 120 min, and 180 min, respectively. The drainage volume during the first 24 h was 50 ml. The ventilation time was 6 h and the ICU stay time was 18 h. The patient was discharged 7 days postoperatively without any complications. Echocardiography before discharge showed no leakage of the VSR or residual cavity around the LVA. 

Acute MI can lead to myocardial necrosis, resulting in LVA and VSR. A sudden left-to-right shunt caused by VSR can induce acute heart failure. Fibrosis of the LVA causes reverse ventricular motion, leading to a dead cavity in the left ventricle and a decrease in cardiac output, which may also induce acute heart failure and malignant arrythmias . Some studies have proposed an interventional approach to close the VSR or LVA . However, it is highly dependent on the anatomy of the VSR and LVA. In this case, the VSR was too close to the apex and did not have an appropriate marginal anchor for the closure device. Moreover, the LVA was too large for an interventional approach in this patient and was not limited to the apex. For these two reasons, it was not possible to perform an interventional procedure for this patient. Generally, the traditional surgical treatment for VSR with concomitant LVA is performed via median sternotomy. However, full sternotomy carries the risk of bleeding and infection . Moreover, sternal integrity negatively affects the motion and stability of the thorax when a patient breathes or exercises, which may delay recovery . An incision in the intercostal space can avoid a sternotomy, causing less bleeding. The preservation of sternal integrity greatly reduces postoperative pain, leading to better thoracic mobility after surgery. Therefore, lateral thoracotomy is not only beneficial for cosmetics but also for rapid mobilization and recovery, especially in a cohort of older or fragile patients. A left lateral thoracic incision is also better to expose the apex. Thus, VSR repair and LVA closure are easier to perform via left lateral thoracic incision than via median sternotomy. 

In this case, the LVA and VSR were successfully repaired via bilateral thoracotomy. We believe that this procedure is a safe and simple technique for treating LVA and/or VSR, with promising outcomes. 

Below is the link to the electronic supplementary material. Supplementary Material 1 

