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 Table of Contents  
CASE REPORT
Year : 2018  |  Volume : 2  |  Issue : 2  |  Page : 118-120

A rare case of true and pseudoaneurysm of left ventricular wall and incremental value of myocardial contrast


Department of Cardiology, Hero DMC Heart Institute, Ludhiana, Punjab, India

Date of Web Publication6-Sep-2018

Correspondence Address:
Dr. Rohit Tandon
Department of Cardiology, Hero DMC Heart Institute, Ludhiana, Punjab
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jiae.jiae_67_17

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  Abstract 

Coexistence of left ventricular true and pseudoaneurysm together is although rare but can be a possible sequelae of ventricular remodeling postmyocardial infarction. True aneurysm can be suspected on the basis of persistent ST-segment elevation on electrocardiogram several weeks after myocardial infarction while pseudoaneurysm can only be diagnosed after a comprehensive echocardiography examination. We describe a rare case of true aneurysm of the left ventricle apex and pseudoaneurysm of midanterior septum wall confirmed by myocardial contrast echocardiography.

Keywords: Myocardial contrast echocardiography, pseudoaneurysm, true aneurysm


How to cite this article:
Kalra GS, Tandon R, Singh B, Mohan B. A rare case of true and pseudoaneurysm of left ventricular wall and incremental value of myocardial contrast. J Indian Acad Echocardiogr Cardiovasc Imaging 2018;2:118-20

How to cite this URL:
Kalra GS, Tandon R, Singh B, Mohan B. A rare case of true and pseudoaneurysm of left ventricular wall and incremental value of myocardial contrast. J Indian Acad Echocardiogr Cardiovasc Imaging [serial online] 2018 [cited 2018 Dec 13];2:118-20. Available from: http://www.jiaecho.org/text.asp?2018/2/2/118/240641


  Introduction Top


Aneurysms of the left ventricle are of two types: true and pseudo. True aneurysms are sequelae of ventricular remodeling posttransmural myocardial infarction while pseudoaneurysm is a mechanical complication of acute myocardial infarction representing contained myocardial rupture. A pseudoaneurysm does not contain all the three layers of the myocardium and is frequently lined by pericardium and mural thrombus [1],[2] and has a tendency to rupture, and therefore, it requires expeditious operative management soon after diagnosis, even in asymptomatic patients.[3] Coexistence of true and pseudoaneurysms is extremely rare. To date, only seven such cases have been reported in the world literature. We report another such case which was corroborated with myocardial contrast echocardiography thus highlighting the progress of routinely available modality in confirming the diagnosis in such a clinical scenario.[3],[4],[5]


  Clinical Presentation Top


A 70-year-old male patient known diabetic and hypertensive for about 12 years presented with chief complaints of dyspnea New York Heart Association Class III for 2 weeks. On examination, the patient was conscious, oriented to time, place, and person, blood pressure was 90/70 mmHg, pulse rate was 90/min, afebrile, no pedal edema, or pallor.

Cardiovascular examination revealed apical impulse in the 5th left intercostal space lateral to midclavicular line, S1 S2 normal, no added sounds. Electrocardiogram-Q wave in anterior leads with ST-segment elevation.

His recent past history was that he had suffered acute anterior wall myocardial infarction 6 weeks back and was thrombolysed with streptokinase. During his previous hospitalization, he had worsening left ventricular failure with progressive pulmonary edema requiring mechanical ventilation for 3 days. Coronary angiography which was done at that time had revealed significant triple vessel disease, so he was advised coronary artery bypass grafting but his relatives refused citing old age and so he was discharged on optimal medical treatment.

Transthoracic echocardiography 8211; apical four-chamber view and apical two-chamber view 8211; showed regional wall motion abnormalities corresponding to left anterior descending territory with large apical true aneurysm and dyskinetic motion of apex [Figure 1] and [Figure 2] and [Video 1] while apical three-chamber view showed left ventricular true aneurysm at apex and suspicion of pseudoaneurysm because there was cutoff of endocardium at midanterior septum level with to-and-fro color flow on color Doppler [Figure 3] and [Video 2]. As the patient was frail and also not consenting for transesophageal echocardiogram (TEE), myocardial contrast echocardiogram was done using SonoVue contrast (phospholipids shell and sulfur hexafluoride gas) in apical three-chamber view; the whole outer margin of pseudoaneurysm could be distinctly appreciated [Figure 4] and [Video 3].
Figure 1: Apical two-chamber view arrow pointing towards large apical true aneurysm with dyskinetic motion

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Figure 2: Apical three-chamber view with green arrow pointing toward left ventricular true aneurysm at apex and yellow arrow pointing towards pseudoaneurysm with cutoff of endocardium at midanterior septum level

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Figure 3: Apical four-chamber view arrow pointing towards true aneurysm at apex

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Figure 4: Apical three-chamber view with myocardial contrast with arrow pointing towards the whole outer margin of pseudoaneurysm

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  Discussion Top


Both true and pseudoaneurysm of the left ventricle are complications of myocardial infarction. A true aneurysm results from gradual thinning of the portion of the ventricular wall after transmural infarction. Pseudoaneurysm occurs after hemorrhagic dissection into an area of transmural infarction and most commonly results in intrapericardial rupture of free wall resulting into cardiac tamponade and death. Rarely, if the overlying pericardium becomes adherent to the epicardium along the surface of the infarct, it can contain the rupture. This then becomes a pseudoaneurysm, its wall being lined by pericardium and mural thrombus.[1]

It is very rare that a true aneurysm may present with a false aneurysm in the same patient and to differentiate both is a great challenge with transthoracic echocardiogram.[5]

To date, only seven cases have been reported in the world literature [4],[5],[6],[7],[8],[9],[10],[11] [Table 1].
Table 1: Case reports of the coexistence of true and false aneurysms

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Of these seven cases (adding the present case), all were men, age ranging from 34 to 75 years. The clinical presentation was from 2 months to 7 years after the initial event. In most cases, the false aneurysms arose from the anterior and anteroapical regions and only one case involved the inferior wall.

In the present case, the aneurysmal complex arose from the apex and apicolateral wall. The clinical presentations varied from asymptomatic or incidental findings to progressive heart failure to frank cardiac tamponade.

Adjunctive tests for accurate localization of pseudoaneurysm of left ventricle include transesophageal echo, computed tomography scan chest, and cardiac magnetic resonance imaging. Myocardial contrast echocardiogram immensely adds to our diagnostic ability for localization of pseudoaneurysm in selected patients as in our case.


  Conclusion Top


In our case, myocardial contrast echocardiogram immensely added to our diagnostic ability by distinctly outlining the whole outer margin of pseudoaneurysm and also excluding any intracavitary thrombus or small leak, thus obviating the choice of TEE, and also TEE is comparatively an invasive procedure and is usually less tolerable by elderly and frail patients, while myocardial contrast opacification of left ventricle can be easily done by intravenous route. Because of the propensity for pseudoaneurysm to rupture, an accurate diagnosis is paramount. Therefore, awareness and vigilance are important for successful surgical management whenever indicated.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Stewart S, Huddle R, Stuard I, Schreiner BF, DeWeese JA. False aneurysm and pseudo-false aneurysm of the left ventricle: Etiology, pathology, diagnosis, and operative management. Ann Thorac Surg 1981;31:259-65.  Back to cited text no. 1
    
2.
Davidson KH, Parisi AF, Harrington JJ, Barsamian EM, Fishbein MC. Pseudoaneurysm of the left ventricle: An unusual echocardiographic presentation. Review of the literature. Ann Intern Med 1977;86:430-3.  Back to cited text no. 2
    
3.
Gobel FL, Visudh-Arom K, Edwards JE. Pseudoaneurysm of the left ventricle leading to recurrent pericardial hemorrhage. Chest 1971;59:23-7.  Back to cited text no. 3
    
4.
Martin RH, Almond CH, Saab S, Watson LE. True and false aneurysms of the left ventricle following myocardial infarction. Am J Med 1977;62:418-24.  Back to cited text no. 4
    
5.
March KL, Sawada SG, Tarver RD, Kesler KA, Armstrong WF. Current concepts of left ventricular pseudoaneurysm: Pathophysiology, therapy, and diagnostic imaging methods. Clin Cardiol 1989;12:531-40.  Back to cited text no. 5
    
6.
Vlodaver Z, Coe JI, Edwards JE. True and false left ventricular aneurysms. Propensity for the altter to rupture. Circulation 1975;51:567-72.  Back to cited text no. 6
    
7.
Coupe M, Dancy M, Pepper J. Coincidence of true and false left ventricular aneurysms after myocardial infarction. Br Heart J 1986;56:567-8.  Back to cited text no. 7
    
8.
Goudevenos J, Parry G, Morritt GN. Subacute rupture of a pseudoaneurysm formed by late rupture of a true left ventricular aneurysm. Br Heart J 1989;62:225-7.  Back to cited text no. 8
    
9.
Morii I, Konishi T, Yagi Y, Nakamura Y, Matsumori A, Fujiwara H, et al. False aneurysm formation during the chronic phase of myocardial infarction at the margin of a previously-detected true aneurysm. Kokyu To Junkan 1992;40:1013-7.  Back to cited text no. 9
    
10.
St. Cyr JA, Fullerton DA. Successful repair of a pseudoaneurysm originating from a true left ventricular aneurysm. Am Heart J 1992;124:1381-2.  Back to cited text no. 10
    
11.
Das AK, Wilson GM, Furnary AP. Coincidence of true and false left ventricular aneurysm. Ann Thorac Surg 1997;64:831-4.  Back to cited text no. 11
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4]
 
 
    Tables

  [Table 1]



 

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