Postinfarction ventricular aneurysms

Postmyocardial Infarction Ventricular Aneurysm: JACC Focus Seminar 5/5

Ventricular aneurysm represents a rare complication of transmural acute myocardial infarction, although other cardiac, congenital, or metabolic diseases may also predispose to such condition. Ventricular expansion includes all the cardiac layers, usually with a large segment involved. Adverse events include recurrent angina, reduced ventricular stroke volume with congestive heart failure, mitral regurgitation, thromboembolism, and ventricular arrhythmias. Multimodality imaging is paramount to provide comprehensive assessment, allowing for appropriate therapeutic decision-making. When indicated, surgical intervention remains the gold standard, although additional therapy (heart failure, anticoagulation, and advanced antiarrhythmic treatment) might be required. However, the STICH (Surgical Treatment for Ischemic Heart Failure) trial did not show any advantage from adding surgical ventricular reconstruction to coronary artery bypass surgery in terms of survival, rehospitalization or symptoms, compared with revascularization alone. Finally, implantable cardiac defibrillator may reduce the risk of fatal arrhythmias.

Post-traumatic Left Ventricular Apical Aneurysm With Endoluminal Thrombus

Here, we report a case of a 54-year-old man who presented with complications of a left ventricle apical aneurysm, which was the result of a myocardial infarction (MI). Interestingly, he sustained the MI following a cardiac contusion whilst playing rugby 32 years ago. He had another MI 10 years later, despite the presence of normal coronary angiography following the initial event, and presented with two episodes of sustained ventricular tachycardia over six months. The patient proceeded to surgical resection of the aneurysm and went on to make a good recovery.

Surgical reconstruction of a giant left ventricular aneurysm with prior unloading using a microaxial pump

A 46-year-old male patient presented with cardiac decompensation due to a giant left ventricular aneurysm combined with a severely reduced left ventricular function after a silent myocardial infarction. Left ventricular unloading was performed with a microaxial pump as a bridge to surgery. Myocardial function in the basal segments was preserved and surgical ventricular reconstruction was performed successfully.

Novel Analysis of Coronary Angiography in Predicting the Formation of Ventricular Aneurysm in Patients With Acute Myocardial Infarction After Percutaneous Coronary Intervention

Background

Ventricular aneurysm (VA) is a serious complication of acute myocardial infarction (AMI), with a very poor prognosis. Early-stage prophylactic treatment is effective in preventing the formation of VAs. However, the existing predictive models for VA formation lack the sensitivity and specificity necessary for evaluating patients with MI. This study aimed to explore the potential use of coronary angiography and establish a more precise prediction model for VA in patients with MI.

Methods

Patients with VA (n = 52) admitted to our medical center between June 2020 and July 2021 with previous emergency percutaneous coronary intervention for AMI were retrospectively included in this database study. Controls that matched 4:1 with the VA cases during the same period were enrolled. The baseline characteristics and coronary angiograms of the enrolled individuals were obtained from the electronic medical record system. The curve length of the distance from the main criminal lesion to its ostia (DLO) and distal (DLD) in the coronary artery were measured with ImageJ. Binary logistic regression analysis was used to identify the predictive factors. The model performance was evaluated by receiver operating characteristic curve analysis.

Results

Binary analysis revealed maximum serum cardiac troponin I level (odds ratio [OR] = 1.046, 95% confidence interval [CI] = 1.027–1.066, P < 0.001), serum brain natriuretic peptide level (OR = 1.001, 95% CI = 1.000–1.002, P = 0.007), left anterior descending artery as the culprit lesion (OR = 5.091, 95% CI = 2.080–12.457, P < 0.001), and that single-vessel disease (OR = 1.809, 95% CI = 0.967–3.385, P < 0.001), stenosis in the main lesion (OR = 1.247, 95% CI = 1.173–1.327, P < 0.001), DLO (OR = 1.034, 95% CI = 1.019–1.049, P < 0.001), DLD (OR = 1.061, 95% CI = 1.043–1.079, P < 0.001), and DLD/DLD (OR = 0.033, 95% CI = 0.010–0.117, P < 0.001) were the independent variables for predicting VA formation in MI patients.

Conclusion

Our study first used quantified information of coronary lesions to establish a predictive model and proved that a longer DLD had the greatest potential in predicting the incidence of VA. Its related parameters including DLO and DLO/DLD ratio were also correlated with the incidence of VA. These findings may provide a new reference for the early identification of high-risk MI patients and preventing VA.

Echocardiographic risk factors of left ventricular thrombus in patients with acute anterior myocardial infarction

AIMS

This study aimed to identify echocardiographic determinants of left ventricular thrombus (LVT) formation after acute anterior myocardial infarction (MI).

METHODS AND RESULTS

This case-control study comprised 55 acute anterior MI patients with LVT as cases and 55 acute anterior MI patients without LVT as controls, who were selected from a cohort of consecutive patients with ischemic heart failure in our hospital. The cases and controls were matched for age, sex, and left ventricular ejection fraction. LVT was detected by routine/contrast echocardiography or cardiac magnetic resonance imaging during the first 3 months following MI. Formation of apical aneurysm after MI was independently associated with LVT formation [72.0% vs. 43.5%, odds ratio (OR) = 5.06, 95% confidence interval (CI) 1.65-15.48, P = 0.005]. Echocardiographic risk factors associated with LVT formation included reduced mitral annular plane systolic excursion (<7 mm, OR = 4.69, 95% CI 1.84-11.95, P = 0.001), moderate-severe diastolic dysfunction (OR = 2.71, 95% CI 1.11-6.57, P = 0.028), and right ventricular (RV) dysfunction [reduced tricuspid annular plane systolic excursion < 17 mm (OR = 5.48, 95% CI 2.12-14.13, P < 0.001), reduced RV fractional area change < 0.35 (OR = 3.32, 95% CI 1.20-9.18, P = 0.021), and enlarged RV mid diameter (per 5 mm increase OR = 1.62, 95% CI 1.12-2.34, P = 0.010)]. Reduced tricuspid annular plane systolic excursion (<17 mm) significantly associated with increased risk of LVT in anterior MI patients (OR = 3.84, 95% CI 1.37-10.75, P = 0.010), especially in those patients without apical aneurysm (OR = 5.12, 95% CI 1.45-18.08, P = 0.011), independent of body mass index, hypertension, anaemia, mitral annular plane systolic excursion, and moderate-severe diastolic dysfunction.

CONCLUSIONS

Right ventricular dysfunction as determined by reduced TAPSE or RV fractional area change is independently associated with LVT formation in acute anterior MI patients, especially in the setting of MI patients without the formation of an apical aneurysm. This study suggests that besides assessment of left ventricular abnormalities, assessment of concomitant RV dysfunction is of importance on risk stratification of LVT formation in patients with acute anterior MI.

Numerical Simulation Study on the Mechanism of Formation of Apical Aneurysm in Hypertrophic Cardiomyopathy With Midventricular Obstruction

Apical aneurysm was observed to be associated with midventricular obstruction (MVO) in hypertrophic cardiomyopathy (HCM). To investigate the genesis of the apical aneurysm, the idealized numerical left ventricular models (finite-element left ventricle models) of the healthy left ventricle, subaortic obstruction, and midventricular obstruction in HCM of left ventricle were created. The mechanical effects in the formation of apical aneurysm were determined by comparing the myofiber stress on the apical wall between these three models (healthy, subaortic obstruction, and midventricular obstruction models). In comparing the subaortic obstruction model and MVO model with HCM, it was found that, at the time of maximum pressure, the maximum value of myofiber stress in MVO model was 75.0% higher than that in the subaortic obstruction model (654.5 kPa vs. 373.9 kPa). The maximum stress on the apex of LV increased 79.9, 69.3, 117.8% than that on the myocardium around the apex in healthy model, subaortic obstruction model, and MVO model, respectively. Our results indicated that high myofiber stress on the apical wall might initiate the formation process of the apical aneurysm.

Biomechanics of infarcted left ventricle: a review of modelling

Mathematical modelling in biomechanics of infarcted left ventricle (LV) serves as an indispensable tool for remodelling mechanism exploration, LV biomechanical property estimation and therapy assessment after myocardial infarction (MI). However, a review of mathematical modelling after MI has not been seen in the literature so far. In the paper, a systematic review of mathematical models in biomechanics of infarcted LV was established. The models include comprehensive cardiovascular system model, essential LV pressure-volume and stress-stretch models, constitutive laws for passive myocardium and scars, tension models for active myocardium, collagen fibre orientation optimization models, fibroblast and collagen fibre growth/degradation models and integrated growth-electro-mechanical model after MI. The primary idea, unique characteristics and key equations of each model were identified and extracted. Discussions on the models were provided and followed research issues on them were addressed. Considerable improvements in the cardiovascular system model, LV aneurysm model, coupled agent-based models and integrated electro-mechanical-growth LV model are encouraged. Substantial attention should be paid to new constitutive laws with respect to stress-stretch curve and strain energy function for infarcted passive myocardium, collagen fibre orientation optimization in scar, cardiac rupture and tissue damage and viscoelastic effect post-MI in the future.

A case report: delayed right ventricular pericardial fistula and aneurysm following penetrating traumatic injury—a controversial aetiology

Background

Right ventricular aneurysms (RVAs) are rare. We present a case with a combined RVA and right ventricular pericardial fistula resulting in a pericardial effusion and cardiac tamponade. The RVA was detected 47 days after the patient suffered a gunshot wound. This report adds to the body of scarce literature on RVA aetiology, diagnoses, and treatment.

Case summary

A 30-year-old male patient presented with worsening respiratory distress over a 7-day period with clinical signs of cardiac tamponade following a history of a gunshot (with associated liver laceration, pulmonary embolism, right nephrectomy, and sepsis) 47 days prior. Transthoracic echocardiography showed a large circumferential pericardial effusion and an RVA. The patient was emergently taken for surgical repair of the RVA.

Discussion

Our case presents a delayed presentation of a gunshot heart and an aetiology with indications of and against a true aneurysm. It brings attention to possible complications of penetrating precordial injuries, with the need for consideration and possible evaluation at follow-up. The literature on the operative excision of RVA is reviewed and various aetiological factors and consequences are discussed.

A Rapid Development of a Right Ventricular Aneurysm Postmyocardial Infarction

Myocardial infarctions may cause ventricular aneurysms. Ischemia-induced ventricular changes are more common in the left ventricle owing to the larger vascular supply, greater volume of myocardium, and increased intra-ventricular pressure. Ischemia-induced right ventricular free wall abnormalities are rare owing to the lower ventricular pressure. The authors describe the echocardiographic progression of a right ventricular ischemic aneurysm resulting from an ST-elevated myocardial infarction in a 71- year-old man. In this E-Challenge, the authors will review the echocardiographic findings and pathophysiology of ischemic aneurysms.

Non-arrhythmic causes of sudden death: A comprehensive review

Sudden cardiac death (SCD) is a major public health issue in the United States and worldwide. It is estimated to affect between 1 and 1.5 million patients worldwide annually, with the global burden expected to rise due to the concomitant rise in coronary artery disease in the developing world. Although arrhythmic causes of SCD such as ventricular tachycardia and ventricular fibrillation are common and well-studied, non-arrhythmic causes are also important, with diverse etiologies from ischemia-related structural heart disease to non-ischemic heart diseases, non-atherosclerotic coronary pathologies, and inflammatory states. Recent research has also found that risk factors and/or demographics predispose certain individuals to a higher risk of non-arrhythmia-related SCD. This review discusses the epidemiology, mechanisms, etiologies, and management of non-arrhythmic SCD.

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.

ST Elevation is not Always Equivalent to Acute Myocardial Infarction: a Case of Brugada Syndrome

Acute myocardial infarction (AMI) is one of the most alerting situations in emergency department. Electrocardiogram (ECG) is one of the most important diagnostic tools and the decision about thrombolytic therapy is usually based upon ECG findings when clinically suspicious. However, ST segment elevation is not always equivalent to acute myocardial infarction. We present a rare syndrome whose ECG shows persistent ST elevation not related to AMI.

The Difference on Features of Fragmented QRS Complex and Influences on Mortality in Patients with Acute Coronary Syndrome

Objectives

To investigate whether the fragmented QRS (fQRS) complexes can be used to distinguish patients with early non-ST elevation myocardial infarction (NSTEMI) from those with unstable angina (UA).

Background

fQRS complex has been found to be linked to myocardial infarction and cardiac death.

Methods

The clinical data of 302 patients who had been diagnosed with coronary artery disease were retrospectively reviewed. Incidence of fQRS complex within 48 h of presentation was analyzed and patients with acute myocardial infarction (AMI) (n = 240) were followed up by telephone interviews for a mean of 61.47 (range, 59.60-63.35) months.

Results

Patients with NSTEMI exhibited higher incidence of fQRS than those with UA (p = 0.047). The incidence of fQRS in the inferior wall leads was significantly higher than that of other leads in patients with anterior wall infarction (p < 0.05). Kaplan-Meier analysis revealed a higher mortality rate in AMI patients with fQRS compared to non-fQRS patients (p = 0.001).

Conclusions

Presence of fQRS complexes within 48 hours of presentation may be used to differentiate NSTEMI patients from UA patients. fQRS may also be used as a survival predictor for patients with AMI.

Effects of Surgical Ventricular Restoration on Left Ventricular Shape, Size, and Function for Left Ventricular Anterior Aneurysm

Background:

Surgical ventricular restoration (SVR) has been performed to treat left ventricular (LV) aneurysm. However, there is limited analysis of changes in LV shape. This study aimed to evaluate the changes in LV shape induced by SVR and the effects of SVR on LV size and function for LV aneurysm.

Methods:

Between April 2006 and March 2015, 18 patients with dyskinetic (dyskinetic group) and 12 patients with akinetic (akinetic group) postinfarction LV anterior aneurysm receiving SVR with the Dor procedure at Chinese People's Liberation Army General Hospital were enrolled in this study. A retrospective analysis was carried out using data from the echocardiography database. LV shape was analyzed by calculating the apical conicity index (ACI). LV end-diastolic volume index, end-systolic volume index, and ejection fraction (EF) were measured. One-way analysis of variance was used to compare means at different time points within each group.

Results:

Within one week after SVR, LV shape became more conical in the two groups (ACI decreased from 0.84 ± 0.13 to 0.69 ± 0.11 [t = 5.155, P = 0.000] in dyskinetic group and from 0.73 ± 0.07 to 0.60 ± 0.11 [t = 2.701, P = 0.026] in akinetic group; LV volumes were decreased significantly and became closer to normal values and EF was improved significantly in the two groups). On follow-up at least one year, LV shape remained unchanged in dyskinetic group (ACI increased from 0.69 ± 0.11 to 0.74 ± 0.12, t = −1.109, P = 0.294), but became more spherical in akinetic group (ACI significantly increased from 0.60 ± 0.11 to 0.75 ± 0.11, t = −1.880, P = 0.047); LV volumes remained unchanged in dyskinetic group, but increased significantly in akinetic group and EF remained unchanged in the two groups.

Conclusions:

SVR could reshape LV to a more conical shape and a more normal size and improve LV function significantly early after the procedure in patients with dyskinetic or akinetic postinfarction LV anterior aneurysm. However, LV tends to be more spherical and enlarged in the akinetic group on at least 1-year follow-up.

Left Ventricular Aneurysm May Not Manifest as Persistent ST Elevation on Electrocardiogram

Patient: Male, 67

Final Diagnosis: Left Ventricular aneurysm post myocardial infarction

Symptoms: Chest pain

Medication: Dual antiplatelet therapy • anticoagulation

Clinical Procedure: Cardiac catheterization

Specialty: Cardiology

Frequency of fragmented QRS in patient with psoriasis vulgaris without cardiovascular disease

Myocardial fibrosis causes the fragmentation of QRS complexes on electrocardiogram. We hypothesized that the frequency of fragmented QRS (fQRS) could be more common in patients with psoriasis vulgaris than in healthy control subjects. In this prospective study, 100 patients with psoriasis vulgaris who did not have any cardiovascular disease were compared with 50 healthy volunteers in control group. The Psoriasis Area Severity Index (PASI) was used for expressing the severity of psoriasis. Patients with psoriasis were categorized according to presence of fQRS in ECG [fQRS (+) group and fQRS (-) group]. Patients with psoriasis had higher frequency of fQRS, higher levels of C reactive protein (CRP) and sedimentation rate (ESR) than the control group (n = 49, 49 % vs. n = 3, 6 %, p < 0.001; 9.91 ± 17.86 vs. 3.59 ± 0.79 mg/dL, p = 0.014; 17.37 ± 17.40 vs. 5.66 ± 5.22 mm/h, p < 0.001, respectively). Within the patient group there was no statistically significant difference between fQRS (+) and fQRS (-) subgroups with regards to sex, disease duration, CRP, ESR, medications and PASI score. It was suggested that presence of fQRS in ECG may be related with myocardial fibrosis in patients with psoriasis who do not have cardiovascular disease. For this reason, in our opinion, fQRS could be used as a predictive marker for myocardial fibrosis in patients with psoriasis.

Left Ventricular Aneurysm Presenting as a Late Complication of Childhood Chemotherapy

Cardiotoxicity is a well known adverse effect of chemotherapy. Multiple cardiac injuries have been reported including cardiomyopathy, pericarditis, myocarditis, angina, arrhythmias, and myocardial infarction. A left ventricular aneurysm due to chemotherapy is a rare and a dangerous complication which is particularly challenging in diagnosis requiring a high index of suspicion and periodic imaging. We present a case of a young Caucasian male with a past medical history of Acute Lymphocytic Leukemia status after chemotherapy during his childhood diagnosed with left ventricular aneurysm several years later.

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.

Fragmented ECG as a risk marker in cardiovascular diseases

Various noninvasive tests for risk stratification of sudden cardiac death (SCD) were studied, mostly in the context of structural heart disease such as coronary artery disease (CAD), cardiomyopathy and heart failure but have low positive predictive value for SCD. Fragmented QRS complexes (fQRS) on a 12-lead ECG is a marker of depolarization abnormality. fQRS include presence of various morphologies of the QRS wave with or without a Q wave and includes the presence of an additional R wave (R’) or notching in the nadir of the R’ (fragmentation) in two contiguous leads, corresponding to a major coronary artery territory. fQRS represents conduction delay from inhomogeneous activation of the ventricles due to myocardial scar. It has a high predictive value for myocardial scar and mortality in patients CAD. fQRS also predicts arrhythmic events and mortality in patients with implantable cardioverter defibrillator. It also signifies poor prognosis in patients with nonischemic cardiomyopathy, arrhythmogenic right ventricular cardiomyopathy and Brugada syndrome. However, fQRS is a nonspecific finding and its diagnostic prognostic should only be interpreted in the presence of pertinent clinical evidence and type of myocardial involvement (structural vs. structurally normal heart).

Predictive value of a fragmented QRS complex in patients undergoing primary angioplasty for ST elevation myocardial infarction

OBJECTIVES

The aim of this study was to evaluate the prognostic value of fragmented QRS (fQRS) on electrocardiography (ECG) patients with acute ST-segment elevation in myocardial infarction (STEMI), who are undergoing primary percutaneous coronary intervention (PCI).

METHODS

We prospectively enrolled 414 consecutive STEMI patients (mean age of 55.2 ± 12.2 years old, range of 26-91-years old) undergoing primary PCI. The study patients were divided into two groups according to the presence or absence of fQRS as shown by ECG in the first 48 hours. The presence of fQRS group was defined as fQRS(+) (n = 91), and the absence of fQRS group was defined as the fQRS(-) (n = 323) group. Clinical characteristics and the one-year outcome of the primary PCI were analyzed.

RESULTS

The patients in the fQRS(+) group were older (mean age 60.7 ± 12.5 vs. 53.6 ± 11.6 years old, P < 0.001). Higher one-year all-cause mortality rates were observed in the fQRS group upon ECG (23.1% vs. 2.5%, P < 0.001, respectively). When using the Cox multivariate analysis, the presence of fQRS on the ECG was found to be a powerful independent predictor of one-year all-cause mortality (hazard ratio: 5.24, 95% confidence interval: 1.43-19.2, P = 0.01).

CONCLUSIONS

These results suggest that the presence of fQRS on ECG was associated with an increased in-hospital cardiovascular mortality, and one-year all-cause mortality in patients with STEMI who are under primary PCI.

Predictive value of the fragmented QRS complex in 6-month mortality and morbidity following acute coronary syndrome

Background

Fragmented QRS encompasses different RSR’ patterns showing various morphologies of the QRS complexes with or without the Q wave on a resting 12-lead electrocardiogram. It has been shown possibly to cause adverse cardiac outcomes in patients with some heart diseases, including coronary artery disease. In view of the need for risk stratification of patients presenting with acute coronary syndrome in the most efficacious and cost-effective way, we conducted this study to clarify the value of developing fragmented QRS in a cohort of patients presenting with their first acute coronary syndrome in predicting 6-month mortality and morbidity.

Methods

One hundred consecutive patients admitted to the coronary care unit at Shahid Madani Heart Center in Tabriz from December 2008 to March 2009 with their first acute coronary syndrome were enrolled in this prospective study. Demographic and electrocardiographic data on admission, inhospital mortality, and need for revascularization were recorded. Electrocardiography performed 2 months after the index event was examined for development of fragmented QRS. Mortality and morbidity was evaluated at 6-month follow-up in all patients.

Results

The patients were of mean age 57.7 ± 12.8 years, and 84% were men. The primary diagnosis was unstable angina in 17 (17%) patients, non-ST elevation myocardial infarction (MI) in 11 (11%), anterior or inferior ST elevation MI in 66 (66%), and postero-inferior MI in six (6%). Fragmented QRS was present in 30 (30%) patients during the first admission, which increased to 44% at the 2-month follow-up and to 53% at the 6-month follow-up. The presence of various coronary risk factors and drug therapy given, including fibrinolytic agents, had no effect on development of fragmented QRS. Mortality was significantly higher (P = 0.032) and left ventricular ejection fraction was significantly lower (P = 0.001) in the fragmented QRS group at the 6-month follow-up.

Conclusion

This study strongly suggests that fragmented QRS on initial presentation with acute coronary syndrome is not predictive of subsequent events but, if present 6 months later, could be predictive of an adverse outcome.

Selective non-operative management of a left ventricular pseudoaneurysm after penetrating cardiac wound

Post-traumatic cardiac pseudoaneurysm (PSA) is a rare, potentially life-threatening complication after penetrating cardiac injury. Early surgical intervention has been the treatment of choice for this sequela due to the risk of rupture. Nevertheless, selective non-operative management (SNOM) has been practiced in patients with postinfarct PSA that are small and stable. We report a case of a post-traumatic cardiac PSA subjected to SNOM.

An unusual case of left ventricular aneurysm in duchenne muscular dystrophy

Duchenne muscular dystrophy (DMD) leads to structural heart disease, including dilated cardiomyopathy, in 90% of patients >18 years of age. Despite the ubiquity of cardiomyopathy associated with DMD, ventricular aneurysms in these patients have rarely been reported. We present a case of a basal inferoposterior aneurysm of the left ventricle in a 23-year-old male patient with DMD.

Fragmented QRS and other depolarization abnormalities as a predictor of mortality and sudden cardiac death

PURPOSE OF REVIEW

Several invasive and noninvasive tests for risk stratification of sudden cardiac death (SCD) have been studied. Tests such as microwave T wave alternans (repolarization abnormality) and signal-averaged ECG (depolarization abnormality) have high negative predictive values but low positive predictive values in patients with heart disease. The presence of a fragmented QRS (fQRS) complex on a routine 12-lead ECG is another marker of depolarization abnormality. The purpose of this review is to discuss the potential utility of tests to detect depolarization abnormalities of the heart for the risk stratification of mortality and SCD with main emphasis on fQRS.

RECENT FINDINGS

fQRS is associated with increased mortality and arrhythmic events in patients with coronary artery disease. fQRS has also been defined as a marker of arrhythmogenic right ventricular cardiomyopathy and Brugada syndrome. In Brugada syndrome, the presence of fQRS predicts episodes of ventricular fibrillation during follow-up.

SUMMARY

fQRS may be of value in determining the risk for SCD and guiding selection for device therapy in patients with structural heart disease and Brugada syndrome. It is possible that the predictive value of fQRS for SCD can be enhanced further by combining a marker of repolarization abnormality such as microwave T wave alternans.

Echocardiographic progression of a subepicardial aneurysm after inferior myocardial infarction

A 62-year-old man presented to hospital with chest oppression. Coronary angiography revealed total occlusion of the right coronary artery and inferior myocardial infarction was diagnosed. He was treated by percutaneous coronary intervention with stenting for myocardial infarction. After four months, echocardiography revealed a huge aneurysm protruding below the inferior surface of the left ventricle. It was considered to be a pseudoaneurysm from the echocardiographic findings. The patient had no symptoms and he refused surgery, so progression of the aneurysm was monitored carefully. At seven months after revascularization, the aneurysm showed a marked increase in size, with a maximal diameter of 48 mm and orifice diameter of 22 mm. Accordingly, the patient agreed to undergo surgical excision. The aneurysm was resected and the defect was closed with a pericardial patch. Pathological examination revealed all of the myocardial elements in the aneurysm wall and thrombus in its lumen. In conclusion, this was a rare case of ventricular subepicardial aneurysm.

The metamorphosis of myocardial infarction following coronary recanalization

The "metamorphosis" of acute myocardial infarction (AMI) in terms of pathological features and complications in the reperfusion era is herein discussed. Typically, the AMI following coronary artery recanalization is characterized by frequent subendocardial location, since a prompt coronary lumen recanalization is able to prevent the transmural progression of myocardial necrosis from the endocardium towards the epicardium. Transmural AMI may develop when recanalization occurs late (>6 hours) or is not effective (persistent coronary occlusion). Moreover, reperfused AMI frequently appears reddish because of interstitial haemorrhage, which is thought to be caused by vascular cell damage with leakage of blood out of the injured vessels. Hemorrhage occurs always within the area of necrosis and it is significantly related to the infarct size and to the coronary occlusion time. At histology, typical features of reperfused AMI consist of contraction band necrosis and interstitial hemorrhage. Moreover, a more pronounced inflammatory cellular response is visible within the necrotic area when comparing reperfused with non-reperfused AMI. Reperfusion after prolonged coronary occlusion is also associated with secondary impairment of microcirculatory flow ("no-reflow" phenomenon), that is due to endothelial swelling, luminal obstruction and external compression but may also be aggravated by distal embolization. Finally, the reperfused AMI with its typical subendocardial, non-transmural location, is characterized by a lower incidence of expansive remodelling and related complications, in terms of cardiogenic shock, myocardial rupture, aneurysm and pseudoaneurysm formation and thromboembolism. Moreover, pericardial involvement is a rare occurrence. Unfavorable mechanical consequences of intramyocardial haemorrhage could consist in increased myocardial stiffness, propensity to wall rupture and delayed healing process. However, prospective in vivo large-scale studies in patients with reperfused AMI are needed to assess the prognostic value of hemorrhagic AMI in terms of morbidity and mortality. The knowledge and correct interpretation of these findings at post-mortem by the general and forensic pathologists is of great importance, to provide useful information to the clinicians.

Discordance of diagnosis of ventricular aneurysm made by the electrocardiogram and myocardial imaging: “ST-segment counterpoise” as a hypothetical mechanism

There is a discordance between ECG and imaging modalities in the diagnosis of ventricular aneurysm (VA) consequent to an old myocardial infarction. A hypothesis is being proposed that this discordance, which results in electrocardiograms (ECGs) not showing ST-segment elevations (+ST) in patients with proven by imaging modalities to have VA (false negative, low diagnostic sensitivity), may be due to "ST-segment counterpoise," rendering the ECG isoelectric. Accordingly, +ST generated by myocardial territories involved with the VA, when poised opposite each other, cancel out via vectorial summation, rendering the ECG falsely negative for VA. Also, a misalignment of the apex longitudinal axis with the left ventricular inflow axis due to myocardial remodeling from the VA (boot-shaped heart) when the apex and another myocardial region are involved with VA leads to +ST cancellation and a false-negative ECG for VA. ST-segment counterpoise as a mechanism rendering the ECG falsely negative for VA can be tested in the future if studies of patients with VA adopt in their methodologies a systematic reporting of severity and topography [corrected] of the regional left ventricular contraction abnormalities, as recommended by the American Society of Echocardiography.

Fragmented left sided QRS in absence of bundle branch block: sign of left ventricular aneurysm

BACKGROUND

A left ventricular aneurysm (LVA) occurs between 3.5% and 9.4% of all cases of acute myocardial infarction. A fragmented left sided QRS (RSR; pattern or its variant RSr;, rSR;, or rSr;) without evidence of bundle branch block (QRS duration <or=120 ms) on the ECG may be associated with a significant myocardial scar, which is the characteristic of a LVA. We, therefore, postulate that fragmented QRS (RSR; pattern or its variant) in the left sided leads (I, aVL, V(3) to V(6)) may be a useful sign of LVA.

METHODS

ECGs of 110 consecutive patients with LVA documented by left ventricular angiography (30 degrees right anterior oblique view) was compared with 220 patients without LVA (110 patients with and 110 patients without coronary artery disease (CAD)), who were evaluated for CAD by symptoms and signs.

RESULTS

The sensitivity of the fragmented QRS for identification of LVA was 50% (55 of 110 patients) and specificity was 94.6% (209 of 220). Within the study population, the positive predictive value of the fragmented QRS for LVA was 83.3% (55 of 66) and the negative predictive value was 79.2% (209 of 264). Based on the range of prevalence of LVA in postmyocardial infarction population (3.5-9.4%) and on observed sensitivity and specificity, the positive predictive value of fragmented QRS for LVA after infarction can be estimated at 29-53% and the negative predictive value can be estimated at 95-98%.

CONCLUSION

The sensitivity of fragmented QRS in left precordial leads for LVA was only 50%, whereas the specificity was 94.5%. It has a relatively low to moderate positive predictive value and high negative predictive value.

Spontaneous rupture of left ventricular true aneurysm

The rupture of left ventricular true aneurysm is a rare event. We report the case of a 52-year-old man who presented to the emergency department with cardiac tamponade that was due to a ruptured left ventricular true aneurysm. An emergency operation was successfully performed to address this rare event.

Left ventricular aneurysm: comprehensive assessment of morphology, structure and thrombus using cardiovascular magnetic resonance

AIM

To demonstrate that cardiac magnetic resonance (CMR) techniques provide unique and definitive information on the presence, location, size and nature of left ventricular aneurysm and pseudoaneurysm, the presence of thrombus and the viability of myocardium.

METHOD

A retrospective study of 27 patients with a final diagnosis of left ventricular aneurysm or pseudoaneurysm, who underwent CMR at a tertiary referral centre in the period between 2000 and 2003.

RESULTS

In 7 cases the correct diagnosis of true aneurysm was confirmed; in 7 cases previously unsuspected thrombus was identified; in 7 cases an unsuspected pseudoaneurysm was identified; and in a further 6 cases a previously unsuspected aneurysm was identified.

CONCLUSION

CMR refined the diagnosis in the majority of patients with left ventricular aneurysm, and should be considered in all cases of confirmed or suspected left ventricular aneurysm.

True aneurysm of the left ventricle: a case report and literature review

Pathologic specimens acquired by anatomy departments may be of fundamental anatomical and clinical interest. In this report we describe a true aneurysm of the left ventricle and we review the relevant clinical records of the patient. A detailed review of the literature on ventricular aneurysms is presented with emphasis on particular aspects of cardiac anatomy.