Subepicardial Aneurysm That Was Diagnosed by Cardiac Imaging and Underwent Successful Surgery

Abstract

A 63-year-old man was admitted because of current chest pain with perspiration for 6 hours. Electrocardiography showed complete right bundle-branch block and ST-segment elevation on leads II, III, aVF, and V 2 through V 6 ( Figure 1); we therefore suspected an anterior and inferior wall acute myocardial infarction. Coronary angiography revealed total occlusion of the proximal left anterior descending artery (Figure 2 and Movie I in the online-only Data Supplement); the left circumflex and right coronary arteries showed no abnormalities. The left anterior descending artery was recanalized by percutaneous catheter intervention. The patient complained of chest pain the next afternoon after percutaneous catheter intervention, and the ECG was not changed. A transthoracic echocardiogram was performed, which demonstrated that the apical segments of the left ventricular walls were akinetic with normal thickness in the 4-chamber view (Movie II in the online-only Data Supplement), but the apex myocardium was dyskinetic with a perforation (2 mm in diameter) connected to a small apical aneurysm (10×5 mm) covered by intact epicardium that communicated with the left ventricular cavity as demonstrated by color Doppler ( Figure 3A and 3B and Movie III in the online-only Data Supplement) from the apical 2-chamber view. This was consistent with a subepicardial aneurysm (SEA). On the follow-up echocardiography performed 8 days after infarction, there was a small thrombus at the apex, and the false aneurysm could not be seen ( Figure 3C and Movie IV in the online-only Data Supplement).To confirm the diagnosis, cardiac magnetic resonance imaging (MRI) was performed. Axial ( Figure 4A) and shortaxis ( Figure 4B) first-pass perfusion steady-state free-precession MRIs demonstrated an area of microvascular obstruction in the apical wall (solid arrows) with an small aneurysm (open arrow) compatible with a left ventricular rupture. The magnified view ( Figure 4C) of the steady-state free-precession MRI confirmed an apical thrombus (arrow) at the area of the ruptured orifice (open arrow) covered by intact epicardium. The 2-chamber-view ( Figure 4D) delayed-enhancement inversionrecovery MRI (steady-state free-precession-gradient recalled echocardiography) after intravenous gadolinium injection showed apical acute myocardial infarction with a persistent area of microvascular obstruction (arrowheads), small apical thrombus, and a small aneurysm with clot covered by epicardium (arrow).To prevent epicardial rupture or sudden death, an aneurysmectomy was performed 28 days after infarction. During surgery, a small ruptured orifice filled with thrombus in the left ventricular apex was evident. A ventricular aneurysm resection and coronary artery bypass saphenous vein to left anterior descending artery side anastomosis operation were performed.Pathological examination showed that the endocardial layer and muscle layer structure ruptured, but the epicardial layer was intact with fibrous tissue and a small number of myocardial cells ( Figure 5). The ...

Progressive intramyocardial dissecting hematoma in the apex of the left ventricle after percutaneous coronary intervention

“…During echocardiography, the appearance of a neocavitation with an echo lucid center in the infarcted myocardium communicating with the ventricular cavity is indicative of an IDH. As it has an intact epicardium, IDH are also known as subepicardial aneurysms, pseudo-false aneurysms, or pseudo-pseudoaneurysms (2)(3)(4)(5). IDH mainly occur after MI, PCI, coronary artery bypass surgery, or cardiac surgery.…”