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Diagnostic Uncertainty Of A Pulsatile Mass After Transapical Beating-Heart Mitral Valve Repair
Navneet Kang1, Amy Brown2, Toshiro Sembo2, Bob Kiaii2, William DT Kent2, Corey Adams2.
1University of Ottawa, Ottawa, ON, Canada, 2University of Calgary, Calgary, AB, Canada.
BACKGROUND: Transapical beating-heart mitral valve repair offers a minimally invasive alternative for select patients unsuitable for conventional surgery or transcatheter edge-to-edge repair. As the technology remains in an early phase of adoption, the full spectrum of mid- and late-term complications has not yet been well defined. We report a mini-thoracotomy site complication that presented with diagnostic uncertainty, highlighting operative decision-making under indeterminate imaging findings.
METHODS: An 85-year-old high-risk patient underwent off-pump transapical beating-heart mitral valve repair via left mini-thoracotomy with initial clinical and echocardiographic success. Six months postoperatively, the patient developed enlarging pulsatile subcutaneous masses at the thoracotomy site without systemic signs of infection. Multimodality imaging, including contrast-enhanced computed tomography and targeted ultrasound, was performed to evaluate for apical pseudoaneurysm versus infected collection. Given persistent diagnostic ambiguity and concern for potential ventricular communication, operative exploration was undertaken with a strategy accounting for both possibilities.
RESULTS: Imaging demonstrated rim-enhancing peri-apical collections extending into the chest wall, with inconclusive Doppler assessment and indistinct interfaces between the myocardium and the collection. Findings exhibited features that could represent either a thrombosed pseudoaneurysm or an infected fluid collection. Peripheral femoral cannulation and cardiopulmonary bypass were established prior to re-entry to mitigate rupture risk. Surgical exploration revealed a loculated abscess tracking along the prior transapical access tract, extending into the pericardium, without myocardial disruption or pseudoaneurysm formation. The apical entry site was intact. Complete debridement and drainage were performed, and the patient was weaned from bypass uneventfully. Postoperative recovery was uncomplicated. Extended microbiologic cultures and molecular testing did not identify an organism.
CONCLUSIONS: Late thoracotomy-site abnormalities following transapical mitral valve repair require multimodal assessment, as structural and infectious complications may present with overlapping clinical and imaging features. Imaging may remain inconclusive due to altered postoperative anatomy. When structural complications cannot be confidently excluded, operative planning should assume the higher-risk diagnosis. As clinical adoption of this technique expands, reporting uncommon complications such as this will help refine surveillance strategies and inform operative decision-making algorithms.
LEGEND:Figure 1. Clinical appearance of thoracotomy-site pulsatile masses.Photograph demonstrating two firm, pulsatile subcutaneous masses beneath the prior left mini-thoracotomy incision. Transmitted cardiac pulsation was noted clinically.
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