Left ventricular true and false aneurysms identified by cardiovascular magnetic resonance

Abstract

ABSTRACT. Left ventricular aneurysms are uncommon complications of myocardial infarction. However, it is important to identify them because they are associated with increased morbidity and mortality. True aneurysms tend to be managed conservatively whereas false aneurysms, because of the risk of rupture, are usually treated with urgent surgery. Distinguishing these two subtypes is therefore critical and cardiovascular magnetic resonance (MR) is being used more frequently to characterise the type of aneurysm as well as to provide clear three-dimensional images of aneurysm morphology. We present a very rare case of a true and a false aneurysm of the left ventricle in the same patient. MR enabled accurate delineation of both aneurysms and the late gadolinium-enhancement images provided evidence confirming both true and false aneurysms to be present. Case reportA 63-year-old female presented with a 2 day history of chest pain. She had experienced brief self-limiting episodes of palpitations associated with dizziness over the preceding month but had otherwise been fit and well. An electrocardiogram showed a regular broad complex tachycardia, consistent with ventricular tachycardia (VT). An attempt at chemical cardioversion with iv amiodarone was unsuccessful, but direct-current (DC) cardioversion reverted the patient to sinus rhythm. A portable chest radiograph showed no obvious abnormality. Transthoracic echocardiography showed an inferior wall left ventricular aneurysm with moderate mitral regurgitation.An adenosine stress cardiovascular magnetic resonance (MR) study was performed (Siemens Avanto 1.5 T, Erlangen, Germany) to look for an ischaemic substrate for VT and to better characterise the inferior wall aneurysm. This revealed no inducible perfusion defect but did demonstrate a large 6 cm wide-necked aneurysm arising from the base of the inferior and inferolateral wall of the left ventricle (LV) close to the mitral valve annulus (Figure 1a). The wall of this aneurysm demonstrated full-thickness late gadolinium enhancement (LGE) with associated mural thrombus (Figure 1b), while the adjacent myocardium in the rest of the inferior and inferolateral wall returned a normal nulled signal. The aneurysm was almost completely surrounded by pericardial fluid (Figure 1a). A further 3.5 cm narrow-necked aneurysm arose from the apex of this larger aneurysm (Figure 1c,d). This smaller aneurysm was adherent to pericardium. Full-thickness LGE was also seen throughout its wall. Further LGE was seen over the pericardial surface close to the smaller aneurysm (Figure 1e). The appearances were therefore those of a large true aneurysm of the inferior wall with an additional false aneurysm arising from its apex.The patient proceeded to surgery urgently given the presence of a false aneurysm. The MR findings were confirmed at surgery, with a large true aneurysm of the basal inferior wall and a small false aneurysm arising from its apex (Figure 2). There was pericardial adhesion to the false aneurysm but not the true aneurysm. The fal...

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