J Thromb Thrombolysis DOI 10.1007/s11239-014-1054-9
A ballooning heart-giant left ventricular apical pseudoaneurysm presenting as congestive heart failure Abhishek Sharma • Saurabh Thakar • Vijay Shetty • Adnan Sadiq • Jacob Shani
Ó Springer Science+Business Media New York 2014
Abstract Left ventricular (LV) pseudo aneurysm is a contained rupture of ventricular wall by adherent pericardium or scar tissue. We present a case of a 70 year-old male presented with exertional dyspnea for 2 months and found to have giant LV pseudo aneurysm on transthoracic echocardiogram, cardiac MRI and angiogram. To our knowledge such a large pseudo aneurysm involving LV apex and presenting as congestive heart failure is the first case in literature. Keywords Pseudoaneurysm LV aneurysm Congestive heart failure
Case report Left ventricular (LV) pseudo aneurysm is a contained rupture of ventricular wall by adherent pericardium or scar tissue. LV aneurysms (both true and pseudo aneurysm) are known complications of myocardial infarction. True aneurysm usually affect anteroapical wall while pseudoaneurysms occur primarily in the posteroinferior wall and basal segments [1]. We present a case of a 70 year-old male presented with progressively worsening of exertional dyspnea and bilateral lower extremity swelling for two months. His past medical history was significant for hyperlipidemia, diabetes mellitus (type II) and posteroinferior non-ST A. Sharma (&) S. Thakar V. Shetty Department of Medicine, Maimonides Medical Center, 1016 50th Street Apt 2C, Brooklyn, NY 11219, USA e-mail: [email protected] A. Sadiq J. Shani Department of Cardiology, Maimonides Medical Center, New York, NY, USA
segment elevation myocardial infarction (NSTEMI, 2 years ago). He was managed medically (with aspirin, metroprolol, enalapril, simvastatin and heparin) for NSTEMI and subsequently underwent invasive angiogram where he was found to have triple vessel disease. At the time of presentation his cardiac examination showed a diffuse apical impulse 4 cm left of the midclavicular line. He was noted to have S3 and 3/6 systolic murmurs in aortic and mitral area on cardiac auscultation. ECG showed sinus rhythm, right bundle branch and left anterior fascicular block with non-specific ST–T wave abnormalities in the precordial and lateral leads. Chest X-ray showed fluid overload. Transthoracic echocardiogram showed mild to moderately decreased LV systolic function (ejection fraction 35–40 %) with global hypokinesis and inferior akinesis, large (approximately 6 cm) LV apical pseudoaneurysm with narrow (1 cm) neck at LV apex, a toand-fro flow seen into pseudoaneurysm, and wall of pseudoaneurysm appears calcified (Figs. 1, 2). Pulse-wave Doppler echocardiogram confirmed to and fro flow across the neck of the pseudoaneurysm (Fig. 2). Echocardiogram also showed moderate left atrium and mild LV enlargement, no evidence of LV hypertrophy, normal right atrium and ventricle chamber sizes, mild aortic stenosis and mitral regurgitation. Cardiac MRI confirmed a large LV apical pseudoaneurysm measuring approximately 6.5 9 7.4 cm with a narrow neck measuring less than 1 cm (Fig. 3). The walls of the pseudoaneurysm were calcified and there was dyskinesia of the apical aneurysm throughout the cardiac cycle, with no evidence of thrombi. LV ejection fraction was estimated to be 25 % when including the aneurysmal sac and 49 % when the aneurysmal sac was excluded. Pigtail catheter could be seen in the narrow neck of the pseudoaneurysm on left ventriculogram (Fig. 4). The cardiac catheterization showed a long, tight lesion with 80 % stenosis of left anterior descending artery (LAD) with calcification, an 80 % stenosis
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A. Sharma et al. Fig. 1 Contrast enhanced 2Dechocardiogram—large left ventricular (LV) apical pseudoaneurysm with narrow neck and a large body
Fig. 2 Pulse-wave Doppler echocardiogram—to and fro flow across the neck of pseudoaneurysm
of the circumflex, and totally occluded right coronary artery. The patient subsequently underwent surgical LV aneurysmectomies with removal of the aneurysm sacs and oversewing of the LV defect, along with coronary artery bypass grafting (CABG) to the LAD coronary artery. Histopathologic examination revealed fibrous tissue, calcification but no thrombi. During CABG, the circumflex coronary artery after incision was found to be heavily calcified, so a
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decision was made not to bypass it and its lumen was reapproximated. The LAD on incision was also found to be calcified, and an endarterectomy was performed before bypass grafting with the internal mammary artery. The post-operative course was uneventful and the patient was discharged to home 1 week later. Pseudoaneurysms involving mitral–aortic intervalvular fibrosa, right ventricular outflow tract, the atria and native
Heart-giant left ventricular apical pseudoaneurysm
LV geometry, causing severe CHF. Pseudoaneurysms are more prone to rupture and early surgical intervention is recommended due to the life-threatening nature of LV pseudoaneurysms; hence every attempt should be made to differentiating them from true aneurysm. However, latter could be challenging task in clinical settings, as pseudoaneurysm can also present with a broad base on echocardiogram. Cardiac MRI and CT scans are innovative diagnostic tools and are preferred by many due to their non-invasive nature [8, 9]. However, left ventriculography is still considered as the best test for the diagnosis of LV pseudoaneurysm.
Fig. 3 Cardiac MRI—large left ventricular apical pseudoaneurysm (white arrow) measuring approximately 6.5 9 7.4 cm with a narrow neck (red arrow) measuring less than 1 cm. The wall of the pseudoaneurysm is calcified with no evidence of thrombi
Conflict of interest
All authors declare no conflict of interest.
References
Fig. 4 Left ventriculogram—pigtail catheter is seen in the neck of the pseudoaneurysm with a large body
and grafted coronary arteries have been reported in the literature; however left ventricle apical pseudoaneurysm is very rare [2–7]. Another peculiar aspect of our case is the large size of the pseudoaneurysm leading to severe ‘blood recruitment’ during cardiac activity and marked disarray of
1. Antman EM (2012) Treatment of ST elevation myocardial infarction. In: Libby P, Braunwald E (eds) Braunwald’s heart disease: a textbook of cardiovascular medicine, 9th ed. Saunders/ Elsevier, Philadelphia 2. Sareyyupoglu B, Schaff HV, Ucar I, Sundt TM 3rd, Dearani JA, Park SJ (2009) Surgical treatment of saphenous vein graft aneurysms after coronary artery revascularization. Ann Thorac Surg 88:1801–1805 3. Sudhakar S, Sewani A, Agrawal M, Uretsky BF (2010) Pseudoaneurysm of the mitral-aortic intervalvular fibrosa (MAIVF): a comprehensive review. J Am Soc Echocardiogr 23:1009–1018 quiz 1112 4. Mack T, Vachon T, Boswell G (2011) Right ventricular outflow tract pseudoaneurysm: two cases. J Cardiovasc Comput Tomogr 5:336–337 5. Yoo D, Robertson G, Block P, Babaliaros V, Lattouf O, Pernetz MA, Martin R, Felner J, Lerakis S (2011) Percutaneous closure of a left atrial appendage pseudoaneurysm. J Am Soc Echocardiogr 24(1):e1–e3 6. Aqel RA, Zoghbi GJ, Iskandrian A (2004) Spontaneous coronary artery dissection, aneurysms, and pseudoaneurysms: a review. Echocardiography 21(2):175–182 7. Rogers JH, De Oliveira NC, Damiano RJ Jr, Rogers JG (2002) Images in cardiovascular medicine. Left ventricular apical pseudoaneurysm: echocardiographic and intraoperative findings. Circulation 105(8):e51–e52 8. Sharma A, Arbab-Zadeh A (2012) Assessment of coronary heart disease by CT angiography: current and evolving applications. J Nucl Cardiol 19(4):796–806 9. Lima JA, Desai MY (2004) Cardiovascular magnetic resonance imaging: current and emerging applications. J Am Coll Cardiol 44(6):1164–1171
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A ballooning heart-giant left ventricular apical pseudoaneurysm presenting as congestive heart failure Abhishek Sharma • Saurabh Thakar • Vijay Shetty • Adnan Sadiq • Jacob Shani
Ó Springer Science+Business Media New York 2014
Abstract Left ventricular (LV) pseudo aneurysm is a contained rupture of ventricular wall by adherent pericardium or scar tissue. We present a case of a 70 year-old male presented with exertional dyspnea for 2 months and found to have giant LV pseudo aneurysm on transthoracic echocardiogram, cardiac MRI and angiogram. To our knowledge such a large pseudo aneurysm involving LV apex and presenting as congestive heart failure is the first case in literature. Keywords Pseudoaneurysm LV aneurysm Congestive heart failure
Case report Left ventricular (LV) pseudo aneurysm is a contained rupture of ventricular wall by adherent pericardium or scar tissue. LV aneurysms (both true and pseudo aneurysm) are known complications of myocardial infarction. True aneurysm usually affect anteroapical wall while pseudoaneurysms occur primarily in the posteroinferior wall and basal segments [1]. We present a case of a 70 year-old male presented with progressively worsening of exertional dyspnea and bilateral lower extremity swelling for two months. His past medical history was significant for hyperlipidemia, diabetes mellitus (type II) and posteroinferior non-ST A. Sharma (&) S. Thakar V. Shetty Department of Medicine, Maimonides Medical Center, 1016 50th Street Apt 2C, Brooklyn, NY 11219, USA e-mail: [email protected] A. Sadiq J. Shani Department of Cardiology, Maimonides Medical Center, New York, NY, USA
segment elevation myocardial infarction (NSTEMI, 2 years ago). He was managed medically (with aspirin, metroprolol, enalapril, simvastatin and heparin) for NSTEMI and subsequently underwent invasive angiogram where he was found to have triple vessel disease. At the time of presentation his cardiac examination showed a diffuse apical impulse 4 cm left of the midclavicular line. He was noted to have S3 and 3/6 systolic murmurs in aortic and mitral area on cardiac auscultation. ECG showed sinus rhythm, right bundle branch and left anterior fascicular block with non-specific ST–T wave abnormalities in the precordial and lateral leads. Chest X-ray showed fluid overload. Transthoracic echocardiogram showed mild to moderately decreased LV systolic function (ejection fraction 35–40 %) with global hypokinesis and inferior akinesis, large (approximately 6 cm) LV apical pseudoaneurysm with narrow (1 cm) neck at LV apex, a toand-fro flow seen into pseudoaneurysm, and wall of pseudoaneurysm appears calcified (Figs. 1, 2). Pulse-wave Doppler echocardiogram confirmed to and fro flow across the neck of the pseudoaneurysm (Fig. 2). Echocardiogram also showed moderate left atrium and mild LV enlargement, no evidence of LV hypertrophy, normal right atrium and ventricle chamber sizes, mild aortic stenosis and mitral regurgitation. Cardiac MRI confirmed a large LV apical pseudoaneurysm measuring approximately 6.5 9 7.4 cm with a narrow neck measuring less than 1 cm (Fig. 3). The walls of the pseudoaneurysm were calcified and there was dyskinesia of the apical aneurysm throughout the cardiac cycle, with no evidence of thrombi. LV ejection fraction was estimated to be 25 % when including the aneurysmal sac and 49 % when the aneurysmal sac was excluded. Pigtail catheter could be seen in the narrow neck of the pseudoaneurysm on left ventriculogram (Fig. 4). The cardiac catheterization showed a long, tight lesion with 80 % stenosis of left anterior descending artery (LAD) with calcification, an 80 % stenosis
123
A. Sharma et al. Fig. 1 Contrast enhanced 2Dechocardiogram—large left ventricular (LV) apical pseudoaneurysm with narrow neck and a large body
Fig. 2 Pulse-wave Doppler echocardiogram—to and fro flow across the neck of pseudoaneurysm
of the circumflex, and totally occluded right coronary artery. The patient subsequently underwent surgical LV aneurysmectomies with removal of the aneurysm sacs and oversewing of the LV defect, along with coronary artery bypass grafting (CABG) to the LAD coronary artery. Histopathologic examination revealed fibrous tissue, calcification but no thrombi. During CABG, the circumflex coronary artery after incision was found to be heavily calcified, so a
123
decision was made not to bypass it and its lumen was reapproximated. The LAD on incision was also found to be calcified, and an endarterectomy was performed before bypass grafting with the internal mammary artery. The post-operative course was uneventful and the patient was discharged to home 1 week later. Pseudoaneurysms involving mitral–aortic intervalvular fibrosa, right ventricular outflow tract, the atria and native
Heart-giant left ventricular apical pseudoaneurysm
LV geometry, causing severe CHF. Pseudoaneurysms are more prone to rupture and early surgical intervention is recommended due to the life-threatening nature of LV pseudoaneurysms; hence every attempt should be made to differentiating them from true aneurysm. However, latter could be challenging task in clinical settings, as pseudoaneurysm can also present with a broad base on echocardiogram. Cardiac MRI and CT scans are innovative diagnostic tools and are preferred by many due to their non-invasive nature [8, 9]. However, left ventriculography is still considered as the best test for the diagnosis of LV pseudoaneurysm.
Fig. 3 Cardiac MRI—large left ventricular apical pseudoaneurysm (white arrow) measuring approximately 6.5 9 7.4 cm with a narrow neck (red arrow) measuring less than 1 cm. The wall of the pseudoaneurysm is calcified with no evidence of thrombi
Conflict of interest
All authors declare no conflict of interest.
References
Fig. 4 Left ventriculogram—pigtail catheter is seen in the neck of the pseudoaneurysm with a large body
and grafted coronary arteries have been reported in the literature; however left ventricle apical pseudoaneurysm is very rare [2–7]. Another peculiar aspect of our case is the large size of the pseudoaneurysm leading to severe ‘blood recruitment’ during cardiac activity and marked disarray of
1. Antman EM (2012) Treatment of ST elevation myocardial infarction. In: Libby P, Braunwald E (eds) Braunwald’s heart disease: a textbook of cardiovascular medicine, 9th ed. Saunders/ Elsevier, Philadelphia 2. Sareyyupoglu B, Schaff HV, Ucar I, Sundt TM 3rd, Dearani JA, Park SJ (2009) Surgical treatment of saphenous vein graft aneurysms after coronary artery revascularization. Ann Thorac Surg 88:1801–1805 3. Sudhakar S, Sewani A, Agrawal M, Uretsky BF (2010) Pseudoaneurysm of the mitral-aortic intervalvular fibrosa (MAIVF): a comprehensive review. J Am Soc Echocardiogr 23:1009–1018 quiz 1112 4. Mack T, Vachon T, Boswell G (2011) Right ventricular outflow tract pseudoaneurysm: two cases. J Cardiovasc Comput Tomogr 5:336–337 5. Yoo D, Robertson G, Block P, Babaliaros V, Lattouf O, Pernetz MA, Martin R, Felner J, Lerakis S (2011) Percutaneous closure of a left atrial appendage pseudoaneurysm. J Am Soc Echocardiogr 24(1):e1–e3 6. Aqel RA, Zoghbi GJ, Iskandrian A (2004) Spontaneous coronary artery dissection, aneurysms, and pseudoaneurysms: a review. Echocardiography 21(2):175–182 7. Rogers JH, De Oliveira NC, Damiano RJ Jr, Rogers JG (2002) Images in cardiovascular medicine. Left ventricular apical pseudoaneurysm: echocardiographic and intraoperative findings. Circulation 105(8):e51–e52 8. Sharma A, Arbab-Zadeh A (2012) Assessment of coronary heart disease by CT angiography: current and evolving applications. J Nucl Cardiol 19(4):796–806 9. Lima JA, Desai MY (2004) Cardiovascular magnetic resonance imaging: current and emerging applications. J Am Coll Cardiol 44(6):1164–1171
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