MRI of cardiac pseudoaneurysm and other complications of myocardial infarction

A giant inferoposterior true aneurysm of the left ventricle mimicking a pseudoaneurysm

A left ventricular aneurysm (LVA) is most commonly the result of myocardial infarction, usually involving the anterior wall. A left ventricular pseudoaneurysm (LVPSA) or false aneurysm forms when cardiac rupture is contained by adherent pericardium or scar tissue. The accurate diagnosis, although difficult to establish, is an important one to make because these aneurysms are prone to rupture. In this article, we report a challenging case of a cardiac aneurysm a year after a coronary bypass operation which could not be definitively diagnosed despite of imaging with different techniques including echocardiography, coronary angiography, left ventriculography and magnetic resonance imaging (MRI). The patient underwent a second cardiac surgery, the aneurysm was resected, the mitral valve was replaced and the defect in the ventricular wall was repaired. Because of the combined diagnostic capabilities like detailed and functional pathoanatomy and aneurysmal wall characterization, MRI seems to have multiple advantages in differential diagnosis.

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.

MR and CT assessment for ischemic cardiac disease

Magnetic resonance imaging and/or contrast-enhanced multidetector computed tomography may be used separately or, often more effectively, in an integrated fashion, to address important issues in patients with coronary artery disease causing ischemic cardiac disease (ICD). These issues include complications of myocardial infarction, such as ventricular dysfunction, myocardial wall rupture, aneurysm formation, intracavitary thrombus, mitral insufficiency, and pericarditis, as well as aspects of planning and monitoring therapy for ICD, such as revascularization and ventricular aneurysm repair.

Clinical characteristics and outcome in postinfarction pseudoaneurysm

The clinical characteristics and outcome in 22 patients with postinfarction pseudoaneurysm were studied. The medium-term outcome was poor (median follow-up 3.6 years), but cardiac rupture was uncommon in patients treated conservatively.

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.

Phosphonate-modified Gd-DTPA complexes. III: The detection of myocardial infarction by MRI

The potential of a phosphonate-modified-Gd-DTPA for MR image enhancement of myocardial infarction has been demonstrated in imaging experiments on rats. The agent, 1-hydroxy-3-aminopropane-1,1-diphosphonate-modified-Gd-DTPA (Gd-DTPA-HPDP) accumulates in two models of myocardial infarction, (i.e., drug-induced diffusely infarcted whole hearts and in focal acute myocardial infarction from a left coronary artery ligation). The time course of the accumulation of the agent in the focal model of infarction and subsequent washout has also been followed in vitro. Results of this kinetics demonstrate that the agent first perfuses all normal fluid spaces and then slowly diffuses into the occluded zone where it is retained for a prolonged period, in sufficient quantities to be useful as an MRI contrast agent. Wash-out of the agent from normal myocardium is fast and complete with MR signal returning to background in minutes. The specificity of Gd-DTPA-HPDP for soft-tissue calcification and its retention within the infarcts permitted imaging at 1 to 2 h postinjection, (after unbound material has cleared the normal tissues). Infarcted tissue appeared as regions of increased signal intensity in T1-weighted images (> 200% enhancement), and correlated with histopathology. Unmodified Gd-DTPA was not retained under identical conditions. Gd-DTPA-HPDP permits a more accurate infarct delineation than is possible with the unmodified agent.