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BMJ Case Reports 2009; doi:10.1136/bcr.07.2009.2107
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A fortunate escape from a broken heart: contained ventricular rupture forming a pseudoaneurysm

  1. Vishal Luther1,
  2. Adarju Gashau2,
  3. John P Davies1,
  4. Inderpaul Birdi1
  1. 1
    Essex Cardiothoracic Centre, Nethermayne, Basildon SS16 5NL, UK
  2. 2
    Basildon and Thurrock University Hospitals NHS Foundation Trust, Nethermayne, Basildon SS16 5NL, UK
  1. Adarju Gashau, AdaGashau{at}doctors.net.uk
  • Published 18 November 2009

A 68-year-old man presented with inferior ST segment elevation myocardial infarction. Thrombolysis failed to result in reperfusion, leading to a completed transmural infarct. Post-infarct echocardiography revealed mildly impaired left ventricular function with inferior akinesia. The patient remained stable before deteriorating into cardiac failure several weeks later. Repeat echocardiography (fig 1) showed the patient had developed a ventricular aneurysm, which had ruptured into the pericardial space. The presence of a new cavity was noted, later confirmed to be a communicating pseudoaneurysm (fig 2). The patient underwent coronary artery grafting and the ruptured ventricular wall was successfully repaired. He made an intermediate recovery.

Figure 1

Transthoracic echocardiogram (apical two chamber view).

Figure 2

Contrast enhanced computed tomography image (sagittal view). Both figures illustrate the ruptured true aneurysm (TA), the resultant pseudoaneurysm (PA), and the communication between both (red arrows).

True ventricular aneurysms develop in 10–15% of cases of transmural infarction.1 The affected wall thins and stretches, bulging outwards during systole.1 Rupture may lead to cardiac tamponade. Pseudoaneurysms occur less commonly and arise from rupture of the ventricular wall contained by adherent pericardial scar tissue, which prevents acute tamponade.2

Clinical differentiation between true and pseudoaneurysm is difficult because both may present with similar features, including chest pain, dyspnoea and hypotension. ST segment elevation and ventricular arrhythmia may also be seen with both.3

On echocardiography, continuity of the myocardium wall is maintained in true aneurysms. These typically appear as bulging areas of myocardium, and are usually found on the anterior ventricular wall. With pseudoaneurysms there is discontinuity of the myocardium wall, extraventricular blood loss, and the presence of a communicating dyskinetic cavity.3

Differentiating true from pseudoaneurysms is important because pseudoaneurysms require emergency surgical intervention.2

Footnotes

  • Competing interests: none.

  • Patient consent: Patient/guardian consent was obtained for publication

REFERENCES

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