Management
Given the large LAAA with concomitant arrhythmias and risk of
thromboembolism, the patient was advised to undergo surgery for removal
of the aneurysm. There is potential risk of a perioperative
thromboembolic event with minimally invasive surgical approach due to
less controlled manipulation of the aneurysm during resection. The size
of aneurysm and presence of thrombus by CT determined our surgical
approach to be median sternotomy with cardiac arrest during
cardiopulmonary bypass (CPB). This approach would give us the most
controlled and low risk scenario during resection. The patient was
placed on CPB after direct cannulation of ascending aorta and
cannulation of right atrium via right common femoral vein approach. The
aorta was cross clamped and Del Nido antegrade cardioplegia was
delivered to the aortic root. Once the heart was decompressed, the large
LAAA was visualized (Figure 5) and careful dissection was performed
along the neck of the aneurysm. A 50 mm AtriCure clip was placed across
base of the LAA and the aneurysm was resected (Figure 5, Video 1).
Histopathological examination confirmed a thin walled LAAA.