Chronic pseudoaneurysm of the left ventricle

Cardiac Outpouchings: Definitions, Differential Diagnosis, and Therapeutic Approach

Background and Aims

Cardiac outpouchings encounter a series of distinct congenital or acquired entities (i.e. aneurysms, pseudoaneurysms, diverticula, and herniations), whose knowledge is still poorly widespread in clinical practice. This review aims to provide a comprehensive overview focusing on definition, differential diagnosis, and prognostic outcomes of cardiac outpouchings, as well as further insights on therapeutic options, in order to assist physicians in the most appropriate decision-making.

Methods

The material reviewed was obtained by the following search engines: MEDLINE (PubMed), EMBASE, Google Scholar, and Clinical Trials databases, from January 1966 until March 2021. We searched for the following keywords (in title and/or abstract): (“cardiac” OR “heart”) AND (“outpouching” OR “outpouch” OR “aneurysm” OR “pseudoaneurysm” OR “false aneurysm” OR “diverticulum” OR “herniation”). Review articles, original articles, case series, and case reports with literature review were included in our search. Data from patients with congenital or acquired cardiac outpouchings, from prenatal to geriatric age range, were investigated.

Results

Out of the 378 papers initially retrieved, 165 duplicates and 84 records in languages other than English were removed. Among the 129 remaining articles, 76 were included in our research material, on the basis of the following inclusion criteria: (a) papers pertaining to the research topic; (b) peer-reviewed articles; (c) using standardized diagnostic criteria; and (d) reporting raw prevalence data. Location, morphologic features, wall motion abnormalities, and tissue characterization were found to have a significant impact in recognition and differential diagnosis of cardiac outpouchings as well as to play a significant role in defining their natural history and prognostic outcomes.

Conclusions

Careful recognition of cardiac outpouchings remains a diagnostic challenge in clinical practice. Due to a broad cluster of distinctive and heterogeneous entities, their knowledge and timely recognition play a pivotal role in order to provide the most appropriate clinical management and therapeutic approach.

Medical Management of a Case of Inferior-Posterior Wall ST Elevation Myocardial Infarction Complicated by Pseudoaneurysm

Left ventricular pseudoaneurysm is a rare complication associated with high morbidity and mortality when symptomatic and is usually managed aggressively to prevent or reduce risk of mortality. Herein, we present the case of a 73-year-old man who underwent coronary artery bypass grafting 10 years ago, now presenting with an inferior-posterior wall myocardial infarction complicated by pseudoaneurysm. This case highlights the need for individual clinical assessment of patient presentation with consideration for medical management in acute settings in patients with pseudoaneurysm of the left ventricle. Despite the natural history of rare complications with pseudoaneurysms such as rupture and potentially fatal cardiac tamponade, infections, and arrhythmias, it is important to note that pseudoaneurysms can present with coronary artery disease and congestive heart failure, and clinicians need to have an index of suspicion for pseudoaneurysms despite advancement in medical and interventional management of coronary artery disease.

Left Ventricular Pseudoaneurysm Complicated With Very Late Rupture 5 Years After Myocardial Infarction

This is a case of a chronic left ventricular pseudoaneurysm after inferior myocardial infarction that remained clinically silent for 5 years before presenting with sudden rupture, leading to hemopericardium and cardiac tamponade. We discuss the importance of surveillance for left ventricular pseudoaneurysms, the limitations of echocardiography, and the critical role of computed tomography angiography imaging to establish the diagnosis and guide therapy. (Level of Difficulty: Beginner.)

Left ventricular false-pseudo and pseudo aneurysm: serial observations by cardiac magnetic resonance imaging

A case of extensive inferior myocardial infarction complicated by a large ventricular aneurysm is presented. Magnetic resonance (MR) imaging 4 days after the onset showed a small protrusion from the necrotic inferior myocardium, which expanded 10 days after onset with a marked pericardial effusion. The follow-up examination by MR and CT imaging 6 months after the onset revealed a large ventricular aneurysm from the inferior cardiac wall. After the aneurysmectomy, the histological study revealed that the aneurysm wall was made up of 2 different types of walls; the peripheral part was a false-pseudo aneurysm and the central part was a pseudo aneurysm. From the serial MR imaging, it is considered that such an aneurysm is primarily formed from a small discontinuation of the LV wall followed by oozing type rupture. Finally, the ruptured central part of the LV wall, which was covered by the pericardium, formed a pseudo aneurysm and the stretched peripheral area, which contains myocardium, formed a false-pseudo aneurysm afterward and then they extended together. Thus, MR imaging provided the important information for the understanding of the formation process of the pseudo and false pseudo LV aneurysm.