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Description
A 33-year-old man presented to the emergency department with sudden substernal chest pain at rest that improved with nitroglycerin. Urgent coronary angiography was performed, which showed complete occlusion of the posterior left ventricular branch of the right coronary artery and left ventricular ejection fraction (LVEF) of 40–45%. He was discharged on medical therapy but was lost to follow-up care. Five months later, the patient was readmitted for acute decompensated heart failure after endorsing orthopnea, swelling and dyspnoea. His symptoms resolved after diuresis and echocardiography revealed LVEF of <20% and what was thought to be a basal inferior wall aneurysm (figure 1A, video 1). He was suspected to have mixed ischaemic and non-ischaemic cardiomyopathy as his prior left heart catheterisation did not demonstrate significant coronary artery disease and was further evaluated for non-ischaemic causes with thyroid stimulating hormone, human immunodeficiency virus, serum and urine protein electrophoresis,and Chagas antibody, which were unremarkable. CT of the chest revealed a complex fluid collection along the inferior border, likely indicative of haemopericardium or thrombus. Closer examination with cardiac magnetic resonance imaging (cMRI) revealed a new large left ventricular pseudoaneurysm (LVP) in the basal to mid-inferior wall (measuring 8.7 cm × 4.4 cm × 5.6 cm) which was contained by a thin pericardial layer and layering thrombus (figure 1B,C). Urgent coronary angiography was performed, which showed an occluded Right Posterolateral Ventricular Branch (RPLV) branch.
Although urgent surgical ventricular repair, transplant evaluation and left ventricular assist device (LVAD) placement were offered at that time, the patient left to seek a second opinion. The patient then presented to our hospital with a persistently depressed LVEF and dilated LV and was deemed a poor candidate for surgical repair. He ultimately underwent orthotropic heart transplantation and made an uneventful recovery.
Both true and pseudoaneurysms can be sequelae of myocardial infarction. However, while a true aneurysm sac contains endocardium, epicardium and thinned fibrous scar tissue, a pseudoaneurysm is a rare phenomenon that often develops after wall rupture that is stabilised by organising adhesions or pericardium.1 Untreated pseudoaneurysms have a high risk for rupture, while rupture of a true aneurysm is uncommon. Thus, early diagnosis of pseudoaneurysms is critical, and resection is indicated in patients with symptoms, expanding pseudoaneurysms, or pseudoaneurysms that are >3 cm in diameter.2
On echocardiography, a pseudoaneurysm is characterised by a narrow neck and a wide apex; however, the neck is not always clearly delineated on standard views.3 Multimodality imaging with multiple axes is recommended for the diagnosis of LVPs, which also allows for clear anatomic delineation and determining surgical options. cMRI is an excellent tool to diagnose LVP, define its anatomy and identify thrombus within the sac. It is particularly helpful in differentiating LVPs from true aneurysms with a reported sensitivity of 100%. LVPs often feature delayed enhancement of the pericardium on cMRI.4 cCTA is a rapid modality that allows for spatial characterisation of the pseudoaneurysm including extent and involvement of adjacent structures.5 Timely diagnosis of LVP is challenging and high degree of suspicion aided by multimodal imaging is particularly warranted.
Learning points
Urgent surgical evaluation is indicated in all patients with left ventricular pseudoaneurysms (LVPs) given the risk of fatal rupture. In general, surgery is strongly advised in symptomatic patients and in patients with expanding pseudoaneurysms or with pseudoaneurysms >3 cm.
Multimodality imaging with multiple axes is recommended for the diagnosis of LVPs, which also allows for clear anatomic delineation and determining surgical options.
Ethics statements
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Footnotes
Contributors SP, KP and LG conceived and planned the manuscript. SP, LG and AE helped gather videos and images. SP led chart review and initial manuscript preparation. LG and AE contributed to image interpretation and assembly. KP assisted with assembly, formatting and editing. All authors provided critical feedback and helped shape the research, analysis and manuscript.
Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.
Case reports provide a valuable learning resource for the scientific community and can indicate areas of interest for future research. They should not be used in isolation to guide treatment choices or public health policy.
Competing interests None declared.
Provenance and peer review Not commissioned; externally peer reviewed.