Pseudoaneurysm of the Left Ventricle Progressing From a Subepicardial Aneurysm

Abstract

pseudoaneurysm of the left ventricle is a rare complication of a myocardial infarction (MI), cardiac surgery, trauma, infection or inflammation, and like a true aneurysm of the left ventricle after MI it may cause left ventricular failure, embolization or ventricular arrhythmia. 1,2 In contrast to a true aneurysm, in which a left ventricular rupture may occur early in the clinical course but is extremely rare in the late phase, a pseudoaneurysm has a propensity to rupture and cause sudden death even in the chronic stage and when it is small. 3 As a result, early diagnosis and surgical exploration of a left ventricular pseudoaneurysm is vital. The features of a subepicardial aneurysm of the left ventricle consist of an abrupt interruption of the myocardium, a narrow neck and a propensity to rupture spontaneously, regardless of its wall's components. [4][5][6] We describe a patient with a huge left ventricular pseudoaneurysm that had progressed from a small subepicardial aneurysm. Case ReportA 56-year-old man had been admitted 6 months previously to the hepatology department of Kansai Medical University Hospital due to an acute hepatitis caused by type B hepatitis virus. The presence of pericardial effusion was suspected based on the abdominal ultrasonography Japanese Circulation Journal Vol.63, July 1999 performed just before his discharge, and echocardiography incidentally revealed an inferior wall MI with a subepicardial aneurysm of the left ventricle (Fig 1a, b). As he had no cardiac symptoms he refused any further examinations or consultations regarding this abnormality and was discharged from the hospital to continue his work as a construction worker there. One month before the current presentation he caught a cold, and although his body temperature recovered to the normal range, both coughing and dyspnea continued and so he re-presented at hospital. The patient's heart rate was 80 beats/min with a regular rhythm. Blood pressure was 118/80 mmHg. The third heart sound was heard at the apex, but no heart murmur was present on auscultation. Laboratory studies were normal. Chest roentgenography revealed a cardiothoracic ratio of 52%, slight pulmonary congestion and an abnormal protrusion at the lower left margin of the cardiac shadow (Fig 2). An electrocardiogram showed a normal sinus rhythm, a left atrial abnormality, Q waves and inverted T waves in leads II, III and aVF (Fig 3). Two-dimensional echocardiography disclosed a huge echo-free space behind the inferior myocardial wall and an abnormal cavity that communicated with the left ventricle through a small hole at the inferior myocardial wall (Fig 1c, d). The blood flows across the hole from the left ventricle to the cavity in systole and from the cavity to the left ventricle in diastole were observed by Doppler color flow imaging (Fig 4). These findings were compatible with a pseudoaneurysm of the left ventricle. Thallium-201 myocardial scintigraphy showed a complete defect of the inferoposterior wall. On radionuclide angiocardiography, a huge abnormal cavi...

Subepicardial aneurysm after anticoagulant therapy for a mural thrombus following anterior myocardial infarction

“…A subepicardial aneurysm is a rare and life-threatening complication of myocardial infarction. [1][2][3][4][5][6] In most cases, it occurs after inferior infarction, whereas a large anterior infarction often complicates true aneurysms with mural thrombi. 7 It is not clear in this case when the endomyocardial rupture occurred, but it is obvious that anticoagulant therapy increased the risk of rupture.…”

Subepicardial Aneurysm Evaluated by Multiplane 2D and Real-Time 3D Volumetric Transesophageal Echocardiography

“…However, conservative medical management is considered unless there are high risk features such as a rapid growth on surveillance imaging studies, progression to pseudoaneurysm, or worsening symptoms. 2,3 Therefore, when a ventriculogram shows an aneurysmal pouch, echo can reveal the status of the epicardium, which is clinically important for management. Furthermore, cardiac MRI and, to a lesser extent, cardiac computed tomography can demonstrate any disruption of the myocardial and pericardial layers with greater spatial resolution.…”