Post Infarction Left Ventricular Pseudoaneurysm Properly Diagnosed Clinically and Angiographically and Successfully Treated Surgically

A case of pseudoaneurysm of the left ventricle following acute myocardial infarction is reported. The condition was accurately diagnosed by left ventricular angiography and successfully treated by surgical resection of a massive false aneurysm.     

Extracardiac left to right shunt in a patient with biventricular postinfarction rupture and pseudoaneurysm

A 68 year old man had a diaphragmatic myocardial infarction and 9 months later was admitted with severe congestive heart failure (functional class IV). Cardiac catheterization demonstrated a postinfarction pseudoaneurysm. Because of a massive left to right shunt (pulmonary to systemic flow ratio = 2.7), concomitant rupture of the ventricular septum was suspected. At surgery the pseudoaneurysm communicated with the right ventricle through two different orifices and with the left ventricle through another ostium. The ventricular septum was intact. Therefore, the shunt was extracardiac through the pseudoaneurysm (left ventricle----pseudoaneurysm----right ventricle). The unique combination of lesions allowed the patient to survive. The false aneurysm was excised and primary repair was performed in the orifices of the right and left ventricular walls. The postoperative course was uneventful and 10 months later the patient was in functional class I.     

Large pseudoaneurysm of the left ventricle after posterolateral wall infarct

Pseudoaneurysms of the left ventricle are rare complications after acute myocardial infarction. We report on a 69 year old patient with a large false aneurysm located in the posterolateral ventricular wall. It became clinically apparent during an episode of severe left heart failure. Echocardiography and left ventriculography allowed an accurate determination of localization and dimension of the pseudoaneurysm; coronary angiography revealed a proximal occlusion of the left circumflex coronary artery. Because of the high risk of rupture, a rapid surgical repair of the false aneurysm was indicated.     

Diagnosis and treatment of left ventricular false aneurysm.

Three patients are presented in whom a false aneurysm of the left ventricle was surgically treated. False aneurysm of the left ventricle is an unusual consequence of ventricular wall rupture with containment of the resulting hematoma. Most false aneurysms of the left ventricle develop following myocardial infarction. The false aneurysm wall contains no myocardium. The false aneurysm has a great tendency to rupture, regardless of its size. One patient developed progressive congestive heart failure following a myocardial infarction. The other two patients were asymptomatic following myocardial infarction. Preoperative magnetic resonance imaging showed characteristics of a false aneurysm. These included a distinct discontinuance of the myocardium at the neck of the aneurysm and a narrow neck relative to the diameter of the aneurysm. Two patients underwent successful closure of the orifice of the false aneurysms. One patient underwent emergency surgery because of acute rupture while awaiting surgery but died of cerebral damage. Surgical correction of a false aneurysm is clearly advisable even in the absence of symptoms.     

Color Doppler evaluation of a specific left ventricular flow pattern in a case of left ventricular pseudoaneurysm

This report describes a case of left ventricular pseudoaneurysm examined by phonocardiography, two-dimensional echocardiography, Doppler color flow mapping, continuous wave and conventional pulsed Doppler echocardiography. The patient had early systolic and early diastolic murmurs. The pseudoaneurysm sac and the site of left ventricular rupture were identified by two-dimensional echocardiography. The flow between the left ventricle and the pseudoaneurysm were imaged by Doppler color flow mapping. Two jets from the left ventricle were directed toward the aneurysm during systole, and from the aneurysm toward the left ventricle in early diastole. Continuous wave Doppler and high pulse repetition frequency Doppler echocardiography demonstrated the maximum flow velocity in systole to be 3 m/sec and in early diastole, 1.7 m/sec. Those flow patterns between the left ventricle and the pseudoaneurysm could have been closely related to the murmur. Doppler echocardiography thus proved useful for detecting specific flow patterns related to a left ventricular pseudoaneurysm.     

Percutaneous device closure of a pseudoaneurysm of the left ventricular wall

The percutaneous device closure of a left ventricular pseudoaneurysm is described in a 60 year old man with a history of myocardial infarction complicated by ventricular tachycardia and left ventricular aneurysm treated by coronary artery bypass grafting and aneursymectomy with ventricular tachycardia ablation. He subsequently developed a vast pseudoaneurysm of the left ventricle with New York Heart Association functional class II heart failure symptoms. The selection of the approach and type of device used to close the neck of the pseudoaneurysm are discussed.     

The value of colour flow mapping in the diagnosis of a combined pseudoaneurysm and large true left ventricular aneurysm

During ultrasound assessment of a large postinfarct apical left ventricular aneurysm, a related localized area of ventricular wall rupture was discovered by colour flow mapping. Other non-invasive and invasive techniques failed to demonstrate the pseudoaneurysm. The rare combination of a true and false left ventricular aneurysm in one patient and the diagnostic difficulties in this case uniquely illustrate the recent controversy concerning the definition and diagnosis of pseudoaneurysm. The clinical importance of colour flow mapping, as the most sensitive technique in detecting pseudoaneurysm, is emphasized.     

磁共振成像在鉴别心肌梗死后左心室室壁瘤中的应用

目的 探讨心脏磁共振成像(MRI)鉴别诊断心肌梗死后左心室真、假性室壁瘤的价值.方法 分析经病理证实的心肌梗死后左心室室壁瘤患者共26例(男22例,女4例).所有患者均行心脏MRI、超声心动图及冠状动脉造影检查,并与病理检查结果对照.结果 患者平均年龄(59.3±9.3)岁.其中胸闷气短24例,15例伴发高血压.超声心动图检查诊断左心室真性室壁瘤22例,假性室壁瘤4例;左心室附壁血栓5例,左心室射血分数为36.9%±9.1%.心脏MRI发现24例患者受累左心室壁厚度＜5.5 mm,2例患者厚度5.5～8.0 mm.24例患者左心室室壁存在矛盾运动,2例患者受累室壁无运动;左心室舒张末期横径(67.8±9.3)mm,室壁瘤最宽处直径(35.1±13.8)mm.心脏MRI诊断真性室壁瘤23例,假性室壁瘤3例,7例患者左心室存在附壁血栓.与病理结果对照,心脏MRI诊断结果与病理一致,而超声心动图检查误诊假性室壁瘤1例,漏诊左心室附壁血栓2例.结论 心脏 MRI 能够准确鉴别心肌梗死后左心室真、假性室壁瘤.

Abstract：

Objective To observe the value of cardiac magnetic resonance imaging(MRI)for differentiation of true from false left ventricular aneurysm in patients after myocardial infraction(MI).Methods Twenty-six patients[22 males/4 females, mean age(59.3 ± 9. 3)years]with left ventricular aneurysm after MI were imaged with MRI, echocardiography and coronary angiography. The respective findings were compared with surgical pathology results. Results There were 24 patients with dyspnea and 15patients with hypertension. LVEF measured by echocardiography was 36. 9% ±9. 1% in this patient cohort.Cardiac MRI showed that the left ventricular end diastolic wall thickness was thinner than 5.5 mm in 24cases, and between 5.5 to 8 mm in 2 cases. The dimension of left ventricle was(67. 8 ± 9. 3)mm.Dyskinesia presented in 24 cases, and akinesia in 2 cases. Delayed enhancement was shown in all cases by MRI. Cardiac MRI detected left ventricular true aneurysm in 23 cases, false aneurysm in 3 case and left ventricular thrombi in 7 cases. The diagnosis by magnetic resonance imaging corresponded well to pathological findings. Echocardiography misdiagnosed pseudoaneurysm in 1 patient, and failed to detected left ventricular thrombi in 2 cases. Conclusion Cardiac MRI could correctly differentiate true from false left ventricular aneurysm in patients after MI.     

An unusual case of postoperative giant left ventricular pseudoaneurysm

Pseudoaneurysms of the left ventricle are rare complications of acute myocardial infarction or cardiac surgery. Three years after aneurysmectomy of a true left ventricular aneurysm, a 66 years old man presented with clinical features of congestive heart failure. The echocardiography showed an extra large chamber next to the posterolateral region of the left ventricle with massive thrombus and severe mitral regurgitation. The diagnosis of pseudoaneurysm was made and was subsequently confirmed by radionuclid angiocardiography and surgical findings. Left ventricular pseudoaneurysm formation is a fairly unusual and serious complication of left ventricular aneurysmectomy with potential catastrophic results. Within the long period of time the pseudoaneurysm insidiously may become giant and may result in heart failure. Recognition of this rare complication of aneurysmectomy has therapeutic importance because surgical correction is necessary. Such pseudoaneurysm formation is easily recognized by two-dimentional echocardiography and radionuclic angiocardiogram. Careful echocardiographic examination is warranted for detecting such a complication in patients after cardiac surgery.     

Echocardiographic diagnosis of pseudoaneurysm of the left ventricle.

The echocardiographic features of postinfarction pseudoaneurysm of the left ventricle are described for the first time. Because ultrasound allows the detection of soft-tissue structures in a manner not possible with other diagnostic techniques, the left ventricular wall can be visualized separating the left ventricular cavity from the saccular aneurysm which is delineated by pericardium and/or extracardiac tissue. In addition to these anatomic findings, relevant qualitative hemodynamic data can also be obtained. Echocardiography seems to be a safe and specific method for the diagnosis of left ventricular pseudoaneurysm. It is suggested that echocardiography should be used in the incipeint phase of pseudoaneurysm formation to detect subacute cardiac rupture.     

Long-term survival of a patient with pseudoaneurysm of the left ventricle following myocardial infarction

A 76-year-old man had an extensively calcified left ventricular pseudoaneurysm which was a sequela of acute myocardial infarction suffered 22 years ago. He experienced acute anterolateral myocardial infarction in January 1964. In March 1964, the presence of a left ventricular aneurysm was suspected by chest radiography and fluoroscopy. He was, however, in good health since then. In April 1986, when he was admitted for treatment of acute bronchitis, a large calcified density was found in the left ventricular region on chest radiography. The electrocardiogram was compatible with an old anterolateral myocardial infarction. Two-dimensional echocardiography showed an immobile portion of the left ventricle which contained "moya-moya" (sluggish, smoky) echoes. A saccular aneurysm of the left ventricle was confirmed by radioisotope cardiac pool scans, reconstruction CT and left ventriculography. Due to the poor general condition of the patient, we followed his course without surgery. He died in October 1986. At autopsy, the pseudoaneurysm was markedly calcified, and its wall was adherent to the parietal pericardium. Histologically, the pseudoaneurysmal structure turned out to be a pseudoaneurysm since the saccular wall contained only scar tissue but no myocardial cells. This is a very rare case of a patient with a left ventricular pseudoaneurysm who survived for 22 years after its occurrence.     

Differentiation of left ventricular pseudoaneurysm from true aneurysm with two dimensional echocardiography

Real time two dimensional echocardiographic findings in four patients with a pathologically proved left ventricular pseudoaneurysm were compared with those in seven patients with a similarly proved true aneurysm of the left ventricle. Pseudoaneurysms produced a bounded echo-free space with a narrow neck that communicated with the left ventricular cavity. The maximal internal width of this neck (O_max) was much smaller than the maximal parallel internal diameter (D_max) of the aneurysmal sac, and the ratio O_max/D_max never exceeded 0.5. In all cases the pseudoaneurysm could be seen extending behind the intact portion of the involved left ventricular wall, and this finding produced a characteristic beak-like configuration in the studies of two patients. In contrast, true aneurysm resulted in local bulging and dilatation of the left ventricular wall so that the maximal internal width of the mouth (O_max) was nearly equal to, or actually represented, the maximal internal diameter (D_max) of the aneurysm so that the ratio O_max/D_max ranged from 0.9 to 1.0. Our preliminary study indicates that real time two dimensional echocardiography is useful in differentiating pseudoaneurysm from true aneurysm of the left ventricle.     

Echocardiographic Findings in a Patient with Left Ventricular Pseudoaneurysm

ABSTRACT A 57-year-old woman, treated for a large anterior transmural myocardial infarction, was readmitted after 8 weeks because of progressive cardiac failure. Chest X-ray showed cardiomegaly with an atypical cardiac silhouette. Two-dimensional echocardiography disclosed a large left ventricular pseudoaneurysm. The patient underwent resection of the false aneurysm with repair of the left ventricular wall and recovered gradually. Different methods for diagnosing pseudoaneurysm are discussed.     

Volumineux faux anévrisme de la pointe du ventricule gauche révélant un infarctus du myocarde silencieux

Left ventricular false aneurysms are rare. They are secondary to a myocardial rupture which is contained by adherent pericardium and scar tissue. LV pseudoaneurysm contains no endocardium or myocardium unlike left ventricular true aneurysm. Most cases of LV pseudoaneurysm are related to acute myocardial infarction in inferior or posterior wall. We report a case of a 56-year-old man with a medical history of chronic cigarette smoking, dyslipidemia, and obesity. The patient had no myocardial infarction before. He was admitted for evaluation of important shortness of breath at effort without chest pain for 5 months. Physical exam find an enlarged left ventricular. The electrocardiogram revealed Q waves and ST segment elevation in leads V1 to V6. Transthoracic echocardiogram showed a large thrombosed apical left ventricular false aneurysm, severe left ventricular dysfunction, which were confirmed by cardiac magnetic resonance imaging, this exam also showed no viability in the mid left anterior descending coronary artery territory. The coronary angiography showed an occlusion of the mid left anterior descending coronary artery and a stenosis of the first diagonal artery. The patient was offered a surgical aneurysectomy with coronary artery bypass. The surgery was successful with amelioration of symptoms. We present a rare case of a giant false left ventricular aneurysm complicating a silent myocardial infarction in the anterior wall. The diagnosis is made by cardiac echocardiogram and cardiac magnetic resonance imaging. Because of the important risk of rupture, the surgical treatment is required.     

Noninvasive evaluation of a left ventricular pseudoaneurysm: Complementary role of echocardiographic and nuclear techniques

This 45-year-old white male was evaluated for congestive heart failure initially ascribed to a rapidly progressive cardiomyopathy. Both radionuclide ventriculography and echocardiography correctly identified a left ventricular pseudoaneurysm as the cause for heart failure. Thallium-201 scintigraphy, by demonstrating a large perfusion defect, suggested a large ostium of the pseudoaneurysm. Following resection of the false aneurysm, a Dacron prosthesis was required to close a large posterior wall defect. We conclude that both radionuclide ventriculography and echocardiography can independently demonstrate a left ventricular pseudoaneurysm. The combined noninvasive approach is able to delineate various anatomical aspects of the pseudoaneurysm and help in planning adequate surgical intervention.     

Echocardiographic findings of posterior wall false aneurysm: case report and review of the literature.

A case of angiographically proven posterolateral left ventricular false aneurysm is presented. The patient underwent successful surgery. The echocardiogram revealed large echo-free spaces behind the posterior wall of the left ventricle, delineated by pericardial echoes and lined internally by extra echoes. These echocardiographic findings are consistent with false aneurysm containing a clot. This report indicates that in patients with previous infarction and distorted cardiac silhouette, echo-cardiography may be helpful in the diagnosis of true or false ventricular aneurysm.     

Left ventricular false aneurysm after coronary bypass surgery: radionuclide diagnosis and surgical resection.

A patient with left ventricular pseudoaneurysm formation resulting from myocardial infarction 4 years after coronary bypass surgery is described. The pseudoaneurysm was diagnosed with gated cardiac blood pool imaging and was subsequently successfully surgically repaired. Postoperative pericardial abnormalities predisposing to the possible development of a false aneurysm are discussed. Also, clinical situations in which pseudoaneurysm should be suspected are described, and appropriate diagnostic approaches are outlined.     

Mitral annular subvalvular left ventricular aneurysm

Annular subvalvular left ventricular aneurysm was first reported in 1962. This type of aneurysm usually arises from the annular subaortic or submitral region of the left ventricle. It should be differentiated from the left ventricular false aneurysm, which was caused by myocardial necrosis. The etiology of subvalvular aneurysm remains unclear. We have presented a case of annular submitral left ventricular aneurysm. The patient had no history of coronary artery disease. Two-dimensional echocardiography and magnetic resonance image (MRI) showed a huge left ventricular aneurysm existed. An annular submitral left ventricular aneurysm was confirmed by an open heart surgery and pathological examination.     

Gro?es Pseudoaneurysma des linken Ventrikels nach Posterolateralwandinfarkt

Zusammenfassung Pseudoaneurysmen des linken Ventrikels sind eine sehr seltene Komplikation nach akutem Myokardinfarkt. Wir berichten über einen 69jährigen Patienten mit ausgedehnten posterolateral gelegenem Pseudoaneurysma, welches durch eine reanimationspflichtige Linksherzdekompensation klinisch manifest wurde. Lokalisation und Ausdehnung des Aneurysmas konnten echokardiographisch und angiographisch sicher quantifiziert werden; koronarangiographisch bestand korrespondierend zur Lokalisation des Aneurysmas ein proximaler Abbruch des Ramus circumflexus. Auf Grund der hohen Rupturgefahr von Pseudoaneurysmen wurde der Patient einer raschen chirurgischen Therapie zugeführt. Summary Pseudoaneurysmus of the left ventricle are rare complications after acute myocardial infarction. We report on a 69 year old patient with a large false aneurysm located in the posterolateral ventricular wall. It became clinically apparent during an episode of severe left heart failure. Echocardiography and left ventriculography allowed an accurate determination of localization and dimension of the pseudoaneurysm; coronary angiography revealed a proximal occlusion of the left circumflex coronary artery. Because of the high risk of rupture, a rapid surgical repair of the false aneurysm was indicated.     

Pseudoaneurysm of the left ventricle complicated by Salmonella typhimurium infection: Recognition by two-dimensional echocardiography

A patient is described with a large posterior left ventricular pseudoaneurysm complicated by Salmonella typhimurium infection. M-mode echocardiography displayed a massive echo-free space behind the posterior left ventricular wall, and two-dimensional echocardiography specifically defined the orifice and saccular contour of the false aneurysm. These findings were confirmed by cardiac catheterization and surgery. The unusual features of Salmonella endovascular infection and the noninvasive methods to detect left ventricular pseudoaneurysms are reviewed.