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.