Pseudoaneurysm of the left ventricle progressing from a subepicardial aneurysm

Cardiac CT and MRI guide surgery in impending left ventricular rupture after acute myocardial infarction

We report the case of a 67 year-old patient who presented with worsening chest pain and shortness of breath, four days post acute myocardial infarction. Contrast enhanced computed tomography of the chest ruled out a pulmonary embolus but revealed an unexpected small subepicardial aneurysm (SEA) in the lateral left ventricular wall which was confirmed on cardiac magnetic resonance imaging. Intraoperative palpation of the left lateral wall was guided by the cardiac MRI and CT findings and confirmed the presence of focally thinned and weakened myocardium, covered by epicardial fat. An aneurysmorrhaphy was subsequently performed in addition to coronary bypass surgery and a mitral valve repair. The patient was discharged home on post operative day eight in good condition and is feeling well 2 years after surgery.

Pseudo-pseudoaneurysm: a rare and unexplored mechanical complication of myocardial infarction

The mechanical complications of myocardial infarction are less frequently encountered in the current era of early revascularization. Complete myocardial rupture, although infrequent, is a potentially lethal complication. The pathology, prognosis, and treatment of complete myocardial rupture are well described in the medical literature. Incomplete cardiac rupture has been less well described, and its prognosis and treatment are less clear. Pseudoaneurysms, subepicardial aneurysms, and pseudo-pseudoaneurysms form the pathologic spectrum of incomplete cardiac rupture. Pseudoaneurysms involve complete myocardial rupture with containment by overlying pericardium, whereas subepicardial aneurysms involve aneurysmal outpouchings contained by epicardium. Pseudo-pseudoaneurysms are a subtype of subepicardial aneurysm consisting of diverticula contained by myocardial elements. Pseudo-pseudoaneurysms follow a variable course. Fibrous tissue may be deposited in the wall of the aneurysm allowing the patient to remain asymptomatic, or the myocardium may progressively dissect with resultant complete ventricular rupture. We describe a case of postinfarction pseudo-pseudoaneurysm that was diagnosed by echocardiography and managed conservatively.