Current concepts of left ventricular pseudoaneurysm: pathophysiology, therapy, and diagnostic imaging methods

Incidental diagnosis of a large left ventricular pseudoaneurysm

Left ventricular pseudoaneurysm is a rare complication of myocardial infarction and represent a myocardial rupture contained within a pericardial space limited by adhesions. Differentiating it from a left ventricular aneurysm can be a real diagnostic challenge. We report a case of a 50-year-old man admitted for symptoms of left heart failure. Transthoracic echocardiography and cardiac computed tomography scan incidentally showed a large lateral left ventricular pseudoaneurysm measuring 75/50 mm in diameter. Patch closure was carried out under cardiopulmonary bypass. Postoperative follow up was uneventful. This case demonstrates the increasing detection of «incidental» left ventricular pseudoaneurysm with more frequent use of multimodality imaging techniques including cardiac CT scan.

A Case of Left Ventricular Pseudoaneurysm as a Complication of Late-Presenting ST-Segment Elevation Myocardial Infarction

This case report delineates the clinical trajectory and management strategies of a 59-year-old Hispanic male diagnosed with a left ventricular pseudoaneurysm (LVPA) following a delayed presentation of ST-segment elevation myocardial infarction (STEMI), for which reperfusion treatment was not administered. Initially, an echocardiogram demonstrated an extensive anterolateral myocardial infarction, severe left ventricular systolic dysfunction, and an early-stage left ventricular apical aneurysm with thrombus, leading to the initiation of warfarin. Metabolic myocardial perfusion imaging via positron emission tomography indicated a substantial myocardial scar without viability, guiding the decision against revascularization. Post discharge, the patient, equipped with a wearable cardioverter defibrillator for sudden cardiac death prevention, experienced symptomatic ventricular tachycardia, which was resolved with defibrillator shocks. Subsequent imaging revealed an acute LVPA adjacent to the existing left ventricular aneurysm. Given the high surgical risk, conservative management was elected, resulting in thrombosis and closure of the pseudoaneurysm after two weeks. The patient eventually transitioned to home hospice, surviving an additional five months. This report underscores the complexities and therapeutic dilemmas in managing post-MI LVPA patients who are ineligible for surgical intervention.

Use of veno-venous extracorporeal membrane oxygenation for stabilization prior to redo sternotomy for aortic pseudoaneurysm repair

Background: Aortic pseudoaneurysms are particularly dangerous because of the risk of rupture and compression of mediastinal structures, including the trachea, and resultant respiratory distress. If respiratory distress progresses to respiratory failure, extracorporeal membrane oxygenation may be used to provide oxygenation prior to or during pseudoaneurysm repair. Case presentation: A 62-year-old male with a history of emergent aortic ascending and arch replacement for Stanford Type A dissection 10 months prior presented to his primary care physician with dyspnea. Chest radiography revealed a widened mediastinum, and subsequent computed tomography angiogram revealed a pseudoaneurysm at the distal suture line of the aortic arch replacement. Due to the location of the pseudoaneurysm, the patient's trachea was compressed, and he was emergently placed on veno-venous (VV) extracorporeal membrane oxygenation (ECMO) following unsuccessful intubation for respiratory distress. Two days later, the patient underwent a redo sternotomy and repair of a 2-3 mm defect in the anterior aspect of the distal suture line of the prior aortic arch replacement. The patient progressed well and was discharged on postoperative day 13. What we learned: Using a combination of peripheral bypass, hypothermic circulatory arrest, delayed closure, and respiratory support, this case demonstrates how even complex patients can be successfully treated with multiple strategies.

Left Ventricular Pseudoaneurysm: A Rare but Fatal Complication of Myocardial Infarction

Left ventricular pseudoaneurysm is a ventricular free wall rupture contained within the adjacent adherent pericardium or scar tissue. Myocardial infarction (MI), cardiac surgery, and chest trauma are the common causes. The most common presenting symptoms of pseudoaneurysms are congestive heart failure, chest pain, and dyspnea, but a small percentage of patients may be asymptomatic. Early diagnosis and treatment are of prime importance because of the tendency of pseudoaneurysms to expand and rupture, with a high mortality rate, especially if left untreated. We present a case of a 65-year-old man who was found to have left ventricular pseudoaneurysm on a follow-up echocardiography within three weeks of an MI. He subsequently underwent patch repair and was discharged after medical optimization. Our case highlights the importance of maintaining a high clinical suspicion of pseudoaneurysm in a patient post-MI, as delayed diagnosis and treatment can be fatal.

Left ventricular pseudoaneurysm: the niche of post-infarction mechanical complications

Left ventricular pseudoaneurysm (LVP) is a very rare, but potentially lethal mechanical complication of acute myocardial infarction (AMI). Despite representing a unique subset of cardiac rupture, it presents peculiar features that distinguish it from both ventricular free-wall rupture (FWR) and ventricular true aneurysm. LVP occurs in less than 0.5% of patients affected by AMI. However, LVP is generally burdened by high mortality, often related to false cavity rupture, leading to catastrophic and often irreversible consequences. The risk of rupture is inversely proportional to the timing from AMI onset, which also determines both the classification of LVP and drives the indication for treatment. Despite the lack of a current consensus on LVP management, urgent surgery is the treatment of choice for LVPs occurring within 3 months from AMI, especially if larger than 3 cm in diameter. A matter of debate, however, is represented by chronic LVPs, especially because the risk of rupture decreases progressively as time passes and left ventricular (LV) false cavity stabilizes. Surgical mortality rate remains not negligible (more than 20%), but these suboptimal results may be considered acceptable, especially considering the lethality associated with the occurrence of pseudoaneurysm rupture. Diagnostic workup is essential for anatomical characterization of LV rupture, which is mandatory to guide the decision on surgical approach and technique for pseudoaneurysm repair. Finally, for a subset of patients with anterior LVP and a well-defined fibrotic neck, and deemed at excessively high surgical risk, percutaneous closure of the cavity has been described with encouraging results.

Unconventional Surgical Intervention for Left Ventricular Pseudoaneurysm Associated With Staphylococcus aureus in a Pediatric Patient

Ventricular pseudoaneurysms are very unusual in children. A six-year-old child developed left ventricular pseudoaneurysm associated with methicillin-sensitive Staphylococcus aureus. The patient responded favorably to antibiotic therapy and ventriculoplasty through an unconventional surgery due to the constrictive pericarditis.

Acute respiratory distress secondary to a huge chronic left ventricular pseudo-aneurysm

Pseudo-aneurysms are a rare, potentially life-threatening complication of a myocardial infarction. We present the case of a 45-year-old male who was brought to the emergency department in extremis and had a previous history of a late presentation inferior ST-elevation myocardial infarction treated percutaneously. Clinical examination revealed evidence of cardiogenic shock, pulmonary edema and a pulsatile epigastric mass. Chest X-ray demonstrated marked cardiomegaly and pulmonary edema. Urgent echocardiography confirmed the presence of a huge basal inferior wall pseudo-aneurysm with bi-directional flow. This was also associated with severe mitral regurgitation, due to posterior mitral annular involvement. The patient was transferred to the local cardiothoracic surgical unit where he underwent emergency repair of the pseudo-aneurysm and mitral valve replacement. Despite the surgery being complex he made a full recovery.

Left ventricular pseudoaneurysm post myocardial infarction

Left ventricular (LV) pseudoaneurysm is a rare and grave complication of acute myocardial infarction. If left undetected, it has an extremely high rate of mortality. It is complicated by a ventricular free wall rupture contained by the pericardium and is characterized by the absence of myocardial tissue in its wall. The clinical presentation of these patients is nonspecific, making the diagnosis challenging. We came across a case of LV pseudoaneurysm diagnosed by transthoracic echocardiography, but unfortunately, the patient passed away within a few hours of presentation in the emergency department. This case depicts the importance of prompt diagnosis and management of such deadly complication.

Multimodality Imaging in a Case of Chronic Massive Left Ventricular Pseudoaneurysm

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LV pseudoaneurysm is a rare but fatal complication of myocardial infarction.

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Multimodality imaging is important in the diagnosis.

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Surgical repair is the mainstay of treatment.

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Conservative management may be necessary in patients with excessive surgical risk.

Percutaneous repair of left ventricular pseudoaneurysm after transcatheter aortic valve replacement

Transcatheter aortic valve replacement (TAVR) represents a viable therapeutic option in patients with severe symptomatic aortic valve stenosis. The development of a left ventricular pseudoaneurysm (LVP) represents an infrequent but potentially catastrophic complication after transapical TAVR. In this case report, we present a patient undergoing TAVR through subclavian access which had an LVP and underwent successful percutaneous closure.

A life-threatening infective pseudoaneurysm of the left ventricle in a toddler

Pseudoaneurysms of the ventricle are an uncommon occurrence in children. They may be secondary to previous cardiac surgery or infection of the pericardial space. Infective pseudoaneurysms require urgent surgery because rupture of the pseudoaneurysm may have catastrophic consequences. The outcome with surgery is excellent. We report a toddler with ruptured pseudoaneurysm secondary to purulent pericarditis who recovered with an emergency surgical closure of the opening of the pseudo-aneurysm.

Imaging of vascular pseudoaneurysms in the thorax and abdomen

INTRODUCTION

This review article illustrates a spectrum of arterial pseudoaneurysms that may occur in various locations throughout the thoracoabdominal region. This article discusses the common etiologies and typical clinical presentations of arterial pseudoaneurysms as well as the imaging modalities employed in their diagnosis and potential treatment options.

OBJECTIVE

The goal of this review article is to familiarize radiologists with the diagnosis of thoracoabdominal arterial pseudoaneurysms, the prompt identification and treatment of which are crucial in this patient population.

CONCLUSION

In summary, a thorough understanding of the etiologies, imaging characteristics, and clinical implications of pseudoaneurysms can help optimize identification and management of this spectrum of disease.

Progression of left ventricular pseudoaneurysm after an acute myocardial infarction

Left ventricular (LV) pseudoaneurysms rarely occur, but are detected more often with the development of new diagnostic tools. Since LV pseudoaneurysms are life-threatening, early surgical intervention is recommended. This report describes an 87-year-old woman with heart failure and a large LV pseudoaneurysm which progressed from a small LV pseudoaneurysm after an acute myocardial infarction over a 1-year period.

An unnatural history of left ventricular pseudoaneurysm?

We report the case of a 79-year-old woman with a history of methicillin-resistant Staphylococcus aureus bacteremia and purulent pericarditis with subsequent subxiphoid pericardiostomy and formation of a large left ventricular pseudoaneurysm (LVPA) that has been medically managed. Long-term survival after pseudoaneurysm formation has traditionally been thought to be unusual without operative intervention. Computed tomography (CT), three-dimensional reconstructed CT, and echocardiographic images documenting the progression of the LVPA are presented over the course of the patient's follow-up. This case highlights the natural history of LVPA and the utility of multimodal imaging in allowing accurate assessment of LVPA anatomy.

Differentiating True Versus Pseudo Left Ventricular Aneurysm

The differentiation of left ventricular pseudoaneurysm from true aneurysm is sometimes difficult. Given the propensity for pseudoaneurysms to rupture leading to cardiac tamponade, shock, and death, compared with a more benign natural history for true aneurysms, accurate diagnosis of these conditions is clinically important. Clinical symptoms, physical examination findings, electrocardiograms, and routine x-rays are not sensitive or specific for diagnosing left ventricular aneurysms nor for distinguishing true from pseudoaneurysm once detected. Our aim is to present a case report demonstrating these difficulties and to review the use of various cardiac imaging modalities in differentiating between these 2 entities.

Left ventricular pseudoaneurysm developing as a late complication of coronary artery bypass grafting with apicoseptal plication

Left ventricular pseudoaneurysm is a false aneurysm, which results from a left ventricle rupture contained by adherent pericardium or scar tissue. The most common etiology of left ventricular pseudoaneurysm is acute myocardial infarction but one-third of pseudoaneurysms develop following surgery. We present a case report of a patient who developed a false aneurysm of the left ventricle 2 months following surgical repair of a left ventricular aneurysm with a concomitant coronary bypass.

Left ventricular pseudoaneurysm causing myocardial infarction and cerebrovascular accident

Although post-infarction mortality is most often due to ventricular dysrhythmias, the non-dysrhythmic causes of post-myocardial infarction death present a potential dilemma to the clinician. Non-dysrhythmic hemodynamic complications include cardiogenic shock, left ventricular free wall rupture, rupture of the interventricular septum, papillary muscle rupture, left ventricular pseudoaneurysm, and acute stroke. We present a rare case of a left ventricular pseudoaneurysm presenting with altered mental status, ultimately suspected to have caused the thromboembolic complications of acute myocardial infarction and cerebrovascular accident.

Large Left Ventricular Pseudoaneurysm Presenting 25 Years After Penetrating Chest Trauma

Penetrating chest wounds leading to damage of thoracic structures are common. A rare sequelae of chest trauma is a contained rupture of the left ventricle of the heart leading to the development of a pseudoaneurysm. This complication needs prompt recognition and repair because of the high likelihood of rupture and death. We report the case of a 47-year-old man who underwent repair of a stab wound to the heart 25 years ago and subsequently developed a large left ventricular pseudoaneurysm and presented with angina.

Ventricular free wall rupture following acute myocardial infarction

SUMMARY

Ventricular free wall rupture remains a dreaded complication of acute myocardial infarction. A dramatic fatal presentation is not universal and if recognized early, especially in its sub-acute form, a therapeutic intervention may be lifesaving. Changing trends in its natural history and the previously described pathological subtypes have emerged since the advent of thrombolysis. Although frequently unpredictable, certain clinical, echocardiographic and electrocardiographic signs should suggest the diagnosis. Moreover, knowledge of predisposing risk factors and a high index of suspicion are helpful in early recognition of this complication. In recent years, several different therapeutic approaches have been described including percutaneous seals and surgical mechanical closure of ventricular free wall rupture. In this review, we sought to highlight established and debatable aspects of this pathology to hopefully enhance prompt diagnosis and treatment by all clinicians caring for patients suffering acute myocardial infarction.

Missed diagnosis of unruptured, huge left ventricular pseudoaneurysm

We report a case of a huge left ventricular pseudoaneurysm following myocardial infarction. Early after myocardial infarction, the pseudoaneurysm was missed during the cardiac examination. The patient underwent coronary bypass surgery with endoaneurysmorraphy of the pseudoaneurysm, and made a satisfactory recovery.

Cardiovascular MR imaging: technique optimization and detection of disease in clinical practice

Magnetic resonance (MR) imaging has emerged as an important and growing means of cardiovascular imaging, with many advantages over other radiologic modalities, including excellent spatial and temporal resolution, lack of ionizing radiation, and noninvasiveness. In this article, the utility of MR imaging in cardiovascular imaging and in the diagnosis of cardiovascular disease will be discussed. MR techniques for evaluating the heart and vasculature will be described, and troubleshooting techniques will be presented. Imaging findings in congenital anomalies such as septal defects, patent ductus arteriosus, transposition of the great arteries, and tetralogy of Fallot will be identified. Valvular lesions and methods for evaluating valvular function will be discussed. MR imaging findings in acquired disorders such as aneurysms and pericardial disease will be described.

Unusual form of cardiac rupture: sealed subacute left ventricular free wall rupture, evolving to intramyocardial dissecting hematoma and to pseudoaneurysm formation--a case report and review of the literature

This report describes an unusual course of rupture of the left ventricular free wall, complicating acute myocardial infarction. Spontaneous sealing of the rupture site enabled close echocardiographic follow-up, during which we monitored the development of intramyocardial dissecting hematoma and, finally, development of a full tear in the left ventricular free wall, leading to the formation of a pseudoaneurysm. The pathophysiology, management, and diagnostic criteria of these processes are being revised.

Pseudoaneurysm of the left ventricle progressing from a subepicardial aneurysm

A 56-year-old man presented with an inferior myocardial infarction and a huge pseudoaneurysm below the inferior surface of the left ventricle, which had progressed from a small subepicardial aneurysm over a 6-month period. Transthoracic echocardiography, Doppler color flow images, radionuclide angiocardiography, magnetic resonance imaging and contrast ventriculography all revealed an abrupt disruption of the myocardium at the neck of the pseudoaneurysm, where the diameter of the orifice was smaller than the aneurysm itself, and abnormal blood flows from the left ventricle to the cavity through the orifice with an expansion of the cavity in systole and from the cavity to the left ventricle with the deflation of the cavity in diastole. Coronary angiography revealed 99% stenosis at the atrioventricular nodal branch of the right coronary artery. At surgery the pericardium was adherent to the aneurysmal wall and a 1.5-cm orifice between the aneurysm and the left ventricle was seen. Pathological examination revealed no myocardial elements in the aneurysmal wall. The orifice was closed and the postoperative course was uneventful. Over-intense physical activity as a construction worker was considered to be the cause of the large pseudoaneurysm developing from the subepicardial aneurysm. These findings indicate that a subepicardial aneurysm may progress to a larger pseudoaneurysm, which has a propensity to rupture, however, it can be surgically repaired.

Role of Echocardiography in Complications Associated with Partial or Complete Rupture of the Myocardium in Acute Myocardial Infarction

In this report, we focus on the specific complications of acute myocardial infarction that are associated with rupture of the myocardium and for which two-dimensional and Doppler color flow echocardiography expedites accurate diagnosis for prompt treatment, including surgical repair, which can be crucial to survival in such cases.

Left ventricular pseudoaneurysm

Left ventricular (LV) pseudoaneurysms form when cardiac rupture is contained by adherent pericardium or scar tissue. Although LV pseudoaneurysms are not common, the diagnosis is difficult and they are prone to rupture. We evaluated the clinical presentation, diagnostic accuracy of imaging modalities, results of therapy and prognosis of 290 patients with LV pseudoaneurysms. Most cases of LV pseudoaneurysm were related to myocardial infarction (particularly inferior wall myocardial infarction) and cardiac surgery. Congestive heart failure, chest pain and dyspnea were the most frequently reported symptoms, but >10% of patients were asymptomatic. Physical examination revealed a murmur in 70% of patients. Almost all patients had electrocardiographic abnormalities, but these were usually nonspecific ST segment changes; only 20% of patients had ST segment elevation. Although radiographic findings were also usually nonspecific, the appearance of a mass was present in more than one half of patients and may be an important clue to the correct diagnosis. Left ventricular angiography was the most definitive test and can be useful in planning surgery since concomitant coronary angiography can be performed. Regardless of treatment, patients with LV pseudoaneurysms had a high mortality rate, especially those who did not undergo surgery. Because the symptoms, signs, electrocardiographic abnormalities and radiographic findings seen in patients with LV pseudoaneurysms can be indistinguishable from those in patients with coronary disease alone, a high clinical index of suspicion is needed to avoid missing the diagnosis.

Coincidence of true and false left ventricular aneurysm

Coincidence of true and false left ventricular aneurysm is very rare. To date 6 cases have been reported in the world literature. We present a case of false aneurysm emanating from a posterior true aneurysm of the left ventricle. These findings were demonstrated preoperatively by transesophageal echocardiography and were confirmed at operation. The aneurysms were successfully resected and the ventricle repaired.

Distinguishing left ventricular aneurysm from pseudoaneurysm. A review of the literature

A postmyocardial infarction left ventricular pseudoaneurysm occurs when a rupture of the ventricular free wall is contained by overlying, adherent pericardium. A postinfarction aneurysm, in contrast, is caused by scar formation resulting in thinning of the myocardium. Although the usual treatment for patients with pseudoaneurysm is urgent surgical repair, the imaging characteristics of pseudoaneurysm and aneurysm, for which treatment is more conservative, are quite similar. The literature on the natural history and imaging characteristics of the two entities is reviewed, and an approach to distinguishing between the two entities is proposed.

Left ventricular pseudoaneurysm presenting twenty-eight months after myocardial infarction. A case report

The authors report an unusually late presentation of a ventricular pseudoaneurysm more than two years after an inferior lateral myocardial infarction and the first case evaluated by Cine loop magnetic resonance imaging.

Successful repair of a ruptured postinfarct pseudoaneurysm of the left ventricle

We report a case of a 60-year-old woman who underwent emergency surgical repair of a ruptured pseudoaneurysm of the left ventricle 10 days after acute myocardial infarction. The repair consisted of oversewing the rupture (2 cm long) on the posterior wall under cardiopulmonary bypass. The patient made a satisfactory recovery.

Angiographic diagnosis of true and false LV aneurysms after inferior wall myocardial infarction

False aneurysms of the left ventricle are rare complications of myocardial infarction. In this unusual case, a 57-year-old male patient had a false aneurysm, that took origin from a true aneurysm in the inferior wall, both discovered 7 years postinfarct. The aneurysms were demonstrable by ventriculography and were resected because of ventricular tachycardia.

Emergency department two-dimensional echocardiography in the diagnosis of nontraumatic cardiac rupture

Myocardial rupture is a catastrophic complication of acute myocardial infarction that usually results in sudden death. If diagnosed quickly, patients with myocardial rupture may be salvaged. This report describes the application of emergency department two-dimensional echocardiography in the diagnosis of six cases of myocardial rupture over two years. Each demonstrated a characteristic hemopericardium on limited single-window examination. These included four patients who met institutional guidelines for thrombolytic therapy. Three patients survived surgical repair, with two long-term survivors.