Ulcerated calcification of the interventricular septum causing Transient Ischemic Attacks: Case Report
© Panagiotou et al; licensee BioMed Central Ltd. 2007
Received: 16 February 2007
Accepted: 17 April 2007
Published: 17 April 2007
Calcific deposits are frequently observed at sites of healed myocardial infarcts. Grossly visible calcification of myocardial infarcts and calcified intracavitary cardiac thrombi are less common but recently are becoming more frequent findings during surgical ventricular restoration procedures.
A 64 years old male diabetic patient experienced two episodes of transient ischemic attacks during the last six months. During the diagnostic work up he was found to have triple vessel coronary artery disease with mild left ventricular dysfunction, akinesia of the anterior-apical wall and hypokinesia of the inferior wall. He was referred to our department for coronary artery bypass grafting. He underwent elective triple coronary artery bypass and a ventricular restoration procedure due to apical wall thinning. The inspection of the left ventricle revealed an ulcerated round shape calcification of the interventricular septum with a crater filled with clot. We resected the above lesion and covered the damaged area with the septal Dacron patch of the modified linear closure. The patient was discharged from the hospital on the 11th postoperative day and has been doing well 6 months later, with improvement in both ventricular function and clinical status.
The exploration of the left ventricular cavity reveals interesting phases of the post-infarction healing process. The suspicion of left ventricular thrombosis in patients with ventricular asynergy justifies a ventricular exploration during coronary artery bypass surgery.
Calcific deposits are frequently observed in human hearts. They are most commonly found in epicardial coronaries, mitral and aortic annular regions, apices of papillary muscles and at sites of healed myocardial infarcts . Grossly visible calcification of myocardial infarcts, and calcified intracavitary cardiac thrombi, are becoming more frequent findings during surgical ventricular restoration procedures [2, 3].
A 64 years old male diabetic patient with coronary artery disease and a history of myocardial infarction had recently experienced two episodes of transient ischemic attacks. The presumed diagnosis was cerebral embolism since an intracranial hemorrhage was excluded and there was no detected ipsilateral carotid stenosis. The patient was in NYHA class III, with no angina. Thallium-201 myocardial scintigraphy showed a combination of scar and viable myocardium in the territory of the occluded left anterior descending.
On coronary angiography he was found to have triple vessel disease, with total occlusion of the left anterior descending branch and of the right coronary artery. Left ventriculography revealed left ventricular dysfunction with a LVEF of 35%, akinesia of the anterior-apical wall and hypokinesia of the inferior wall. He was referred to our department for coronary artery bypass grafting.
The operation was performed with the aid of cardiopulmonary bypass, moderate hypothermia and intermittent combined (retro and antegrade) cold blood cardioplegia. Intraoperatively the apical walls were found to be thin and scared and collapsed with ventricular venting.
The area of the endocardiectomy together with the infracted peripheral septum was covered with a Dacron patch. Consequently this septal patch was incorporated in the linear closure of the anterior-apical ventriculotomy .
Postoperative recovery was uneventful. He was discharged from the hospital on the 11th postoperative day and is doing well 6 months later, with improvement in both ventricular function (LVEF 45%) and clinical status (NYHA class I).
Left ventricular thrombus formation may occur in the early course after acute anterior myocardial infarction. Delayed thrombus formation is always associated with wall motion deterioration. Oral anticoagulant therapy is strongly recommended in these patients and associated with thrombus resolution and decrease of embolic events. Some times persistent LV mural thrombi may become encapsulated by thickened and calcified endocardium .
The inspection of the LV cavity performed during SVR procedures, reveals different stages of the post-infarction ventricular healing process, previously less well recognized.
The accepted indication for an SVR procedure according to the experience is a >35% asynergy of the left ventricular perimeter . In cases with less extent of apical involvement but with significant wall thinning, a 'prophylactic' anti – remodeling muscle procedure is common practice . Some surgeons are performing this procedure without even a ventriculotomy, by stitching 'blindly' the ventricular apex from outside. They define such a procedure as a minimally invasive one or an 'off-pump' ventricular restoration. The later procedure must be an absolute contraindication in cases with suspected ventricular thrombi, which in the author's experience are not rare even in patients on anticoagulation treatment.
Inspection of the left ventricular cavity in ischemic cardiomyopathy patients with apical asynergy reveals interesting phases of the post-infarction healing process. Utilizing a lower decision threshold for a ventriculotomy and surgical ventricular restoration surgery can be advantageous especially in coronary patients with segmental asynergy and suspected ventricular thrombi.
- SVR :
Surgical Ventricular Restoration Procedure
- LV :
- LVEF :
Left Ventricular Ejection Fraction
Written consent was obtained from patient's relative for publication of study.
- Roberts W, Kaufman R: Calcification of myocardial infarcts. Am J Cadiol. 1987, 60: 28-32. 10.1016/0002-9149(87)90978-7.View ArticleGoogle Scholar
- Morales C, Bernal JM, Rabasa JM, Gutierez F, Val F, Revuelta JM: The fine art of nature. J Thorac Cardiovasc Surg. 1997, 114: 491-2. 10.1016/S0022-5223(97)70199-5.View ArticlePubMedGoogle Scholar
- Greaves SC, Zhi G, Lee RT, Solomon SD, MacFadyen J, Rapaport E, Menapace FJ, Rouleau JL, Pfeffer MA: Incidence and natural history of left ventricular thrombus following anterior wall acute myocardial infarction. Am J Cardiol. 1997, 80: 442-8. 10.1016/S0002-9149(97)00392-5.View ArticlePubMedGoogle Scholar
- Micklebororough LL, Carson S, Ivanov J: Repair of dyskinetic or akinetic left ventricular aneurysm: Results obtained with a modified linear closure. J Thorac Cardiovasc Surg. 2001, 121: 675-682. 10.1067/mtc.2001.112633.View ArticleGoogle Scholar
- Auer J, Berent R, Lassnig E, Weber T, Eber B: Calcified left ventricular thrombus in a patient after myocardial infarction. Int J Cardiol. 2002, 82: 185-186. 10.1016/S0167-5273(01)00610-6.View ArticlePubMedGoogle Scholar
- Menicanti L, Di Donato M: The Dor procedure: What has changed after fifteen years of clinical practise. J Thorac Cardiovasc Surg. 2002, 124: 886-90. 10.1067/mtc.2002.129140.View ArticlePubMedGoogle Scholar
- De Bonis M, Alfieri O: Surgery Insight: surgical methods to reverse left ventricular remodelling. Nat Clin Pract Cardiovasc Med. 2006, 3: 507-13. 10.1038/ncpcardio0631.View ArticlePubMedGoogle Scholar
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