Echocardiographic Findings of Posterior Wall False Aneurysm Case
Report and Review of the Literature
Agop Aintablian, M.D., F.A.C.A., Robert I. Hamby, M.D., and Jonathan R. Jaffe, M.D., F.A.C.A. NEW HYDE
PARK,
NEW YORK
One of the major complications of myocardial infarction is the development of ventricular aneurysm.1-4 According to the criteria (clinical, angiographic, or pathologic) used by some authors, the incidence of ventricular aneurysm following myocardial infarction varies between 3.8 and 38%.1-4 Postinfarction aneurysms are usually true rather than
Center in September 1976 for further evaluation of the recent onset of compensated congestive heart failure and an abnormal chest x-ray. He was in good health until March 1976, when he had a serious car accident associated with loss of consciousness. Work-up in another hospital failed to reveal any fractures or abnormalities in the chest x-ray or elec-
false,
trocardiogram.
or
they
are
pseudoaneurysms.
Noninvasive condense M-mode echocardiography has been attempted in patients with ventricular aneurysm.5-’ The diagnosis of a pseudoaneurysm utilizing similar methodology is rare. To out
He returned to work and did well until June 1976. At that time, while at work, he experienced a localized retrosternal burning sensation, which recurred intermittently thruughuui the day. He was seen in an emergency room and, because of a normal electrocardiogram, was sent home. The following day, because of the recurrence of this burning sensation, he
knowledge, echocardiographic findings of a posterior wall pseudoaneurysm have been described in only two cases.’-’ Also, Davidson and associates&dquo; recently reported echocardiographic findings in a patient with anterior wall pseudoaneurysm. We are now reporting another case of echocardiographic documentation of angiographically proven posterior wall false aneurysm in a patient who underwent successful surgery.
hospitalized. During the hospitalization, he developed fever and bilateral pleural effusion, was
and
’
.
’
Case Report
.
A to
it
was
noted
that
his elec-
trocardiogram showed evolutionary changes of a true posterior wall myocardial infarction. Despite an extensive work-up, no specific cause was found for the bilateral exudative pleural effusion
68-year-old white man was admitted Long Island Jewish-Hillside Medical
and a fever of 103°F. After 2 weeks the fever subsided, the pleural effusion resolved, and he was discharged with the diagnosis of pericarditis. At that time the cardiac silhouette, on repeat chest x-ray, was within normal limits. After discharge, he did well until 5 weeks before the present admission, when he was admitted to another hospi-
From the Department of Medicine, Division of Cardiology, Long Island Jewish-Hillside Medical Center, New Hyde Park, New York, Queens Hospital Center Affiliation, Jamaica, Queens, and the School of Medicine, Health Sciences Center, State University of New York at Stony Brook, Stony Brook, New York.
284
Downloaded from ang.sagepub.com at UNIV OF MONTANA on April 3, 2015
285
FIG. 1. Posteroanterior chest roentgenogram the left border of the heart, which was
ing from
demonstrating (arrow) a mass bulginterpreted as a probable ventricular
aneurysm.
tal because of the onset of congestive heart failure with ankle edema, hepatomegaly, and bilateral rales. After digitalization and diuresis, it was noted that his chest x-ray now showed an abnormal bulge of the left cardiac border. Right heart catheterization revealed normal
pressures and
globular
a
posterolateral, large,
aneurysm of the left ventricle.
At this
time, he was transferred to our for further evaluation. Upon hospital was he transfer, asymptomatic and on no medication. There was no history of angina pectoris, myocardial infarction, hy-
Downloaded from ang.sagepub.com at UNIV OF MONTANA on April 3, 2015
286 or diabetes mellitus. Physical examination revealed a blood pressure of 120/80 mm Hg and a regular pulse rate of 80 per minute. Cardiac examination revealed the apical impulse within the fifth left intercostal space in the midclavicular line. There were no thrills, murmurs, or rubs, except for a prominent S4 gallop. There was no ankle edema, hepatomegaly, or neck vein distention. The rest of the physical examination was normal. An admission chest x-ray (Figure 1 ) showed a bulge on the left cardiac border, which, on a lateral x-ray, appeared to be contiguous to the left ventricle. The electrocardiogram revealed normal sinus rhythm, with tall R waves in leads VI to V3, suggesting a dorsal myocardial in-
pertension,
farction. Laboratory data, including urinalysis, routine blood tests, enzyme studies, serum lipid profiles, as well as a 3hour glucose tolerance test, were all normal. On September 9, 1976, a complete right and left cardiac catheterization and coronary angiograms were performed. They revealed slight elevation of the right heart, pulmonary wedge, and left ventricular end-diastolic pressures. Left
ventricular angiograms, performed in the RAO, LAO, and AP projections, showed normal left ventricular wall motion with a large ventricular aneurysm on the posterolateral aspect of the left ventricle (Figure 2). Selective coronary angiograms demonstrated an isolated, complete cutoff of the circumflex artery,
FIG. 2.Levophase of a pulmonary angiogram in the right anterior oblique (A and B) and left anterior oblique (C and D) projections during end-diastole and end-systole. The arrow points to the left ventricular false aneurysm, which seems to expand during systole (B and D).
Downloaded from ang.sagepub.com at UNIV OF MONTANA on April 3, 2015
287
FIG. 3. Condense M-mode echocardiographic scan demonstrating a normal-sized left ventricular chamber with good septal and posterior wall motion. Behind the left ventricular posterior wall, extending from the atrioventricular junction up to the apex, there is an echo-free space (EFS) lined internally by a few extra echoes consistent with a thrombus. Posteriorly, the echo-free space is delineated by pericardial echoes (thin arrows), which, during systole, move in directions opposite to the left ventricular posterior wall.
with normal right anterior descending coronary artery, and 40-50% proximal stenosis of the left anterior descending coronary artery. The echocardiographic examination
carried out with a commercially available Eckoline 20A Ultrasonoscope connected to a Honeywell strip chart recorder and 2.25 mHz, 0.75 inch diameter transducer focused at 7.5 cm. With the patient in a slight left lateral decubitus position, echocardiograms of the aortic and mitral valves were recorded from the fourth intercostal space in the parasternal area, first by identifying the anterior leaflet of the mitral valve and then by rotating the transducer superiorly and medially until the aortic root was identified. Once these structures were identified, several condense M-mode scans were taken and, with inferolateral angulation of the ultrasonic beam, echoes were recorded from the left ventricular was
chamber and the apex. At times, apical echoes were best recorded with the patient in a supine position rather than in a slight left lateral decubitus position. An echocardiographic study performed at this time revealed (Figure 3) a normal-sized left atrium, left ventricle, and right ventricle, with good septal and posterior wall motion. Behind the left ventricular posterior wall, there was a large echo-free space (EFS) delineated by the pericardium and containing a cluster of extra echoes. Since the echofree space did not extend behind the apex and only the pericardium formed the posterior wall of the echo-free space, we diagnosed a pseudoaneurysm of the posterior wall of the left ventricle, rather than a loculated pericardial effusion. The patient underwent left ventricular
aneurysmectomy, which, according
to
the surgical note, measured 8-9 cm on the posterior aspect of the left ventricle,
Downloaded from ang.sagepub.com at UNIV OF MONTANA on April 3, 2015
288 with an opening of 4 cm. It was densely adherent to the pericardium, with an extremely thin free wall paradoxically bulging out during systole. A fair amount of scarring of the surrounding muscle was noted, and inside the aneurysmal sac there was a small amount of laminated thrombus. The pathology report revealed a dense layer of fibrous tissue, with the epicardial surface showing mesothelial proliferation, diagnostic of a false aneurysm with a mural thrombus and chronic pericarditis. After an uneventful postoperative course, the patient was discharged on digoxin. Two months after discharge, he continued to do well with no restriction of his activities.
Discussion The distinction between left ventricular true and false aneurysm is based on pathologic and angiographic findings. In a true aneurysm, the aneurysmal wall is formed by infarcted myocardial tissue containing, primarily, fibrous tissue, among which elements of the ventricular wall may be identified.&dquo; Gradual bulging of this segment will result in a widemouthed aneurysm, whereas in a false aneurysm, which results from an organized hematoma secondary to rupture of the heart, the wall contains fibrous tissue, and no elements of the cardiac wall are retained by the pericardium. A false aneurysm typically has a narrow mouth, which can be identified angiographically to distinguish it from a true aneurysm. Both true and false ventricular aneurysms contain mural thrombi.1O-12 Except for rupture of the heart, patients with true or false left ventricular aneurysm have essentially similar clinical manifestations.7,8,13 Antemortem angiographic documentation of false aneurysm is very rare, since chronic false aneurysm has the potential for rupture.10,13 Although true aneurysm may, on rare oc-
casion, rupture in the early stages of aneurysmal formation, once the fibrous the potential for rupture is small.lo,l3 extremely To our knowledge, only five cases of left ventricular false aneurysm have been
stage is
over,
diagnosed angiographically, 13-16 and one by radioisotope-gated cardiac blood pool imaging.17 Echocardiographic features of left ventricular posterior wall false aneuysm have been reported only twice.8,g Our patient demonstrated an echofree space posterior to the left ventricular wall, the outer contour of which was formed by the pericardium and was lined internally by extra echoes corresponding to a laminated thrombus. It should be mentioned that in this case echo-free space did not extend around the apex of the left ventricle, which distinguishes it from a massive and nonloculated pericardial effusion. Although a loculated,
large pericardial effusion, posterior mediastinal cyst, or pericardial tumor&dquo; cannot be
ruled out
on
the basis of these
echocardiographic findings, considering the overall clinical presentation of this patient with an abnormal bulge on his chest x-ray and paradoxical motion of posterior pericardium, there is no doubt that the diagnosis of pseudoaneurysm of the left ventricular posterior wall was more appropriate than a diagnosis of loculated pericardial effusion. We conclude that a condense M-mode echocardiographic scan is a valuable noninvasive tool, which can be useful in diagnosing ventricular true and false aneurysms. It is our opinion that the condense M-mode echocardiographic scan should be used in all patients who, after myocardial infarction, develop cardiomegaly with recurrent ventricular tachyarrhythmias, congestive heart failure,
unexplained
murmur, or recurrent
hypo-
tension with distorted cardiac silhouette-features that suggest ventricu-
Downloaded from ang.sagepub.com at UNIV OF MONTANA on April 3, 2015
289 lar true or false aneurysm or subacute cardiac rupture. Since patients with false aneurysm and subacute cardiac rupture are amenable to successful surgery, bedside echocardiography in the coronary care unit may help detect these patients, who otherwise may die if these diagnoses are missed or prompt angiographic confirmation and surgery are not performed.
Summary A
case
and distorted cardiac silhouette, echocardiography may be helpful in the diagnosis of true or false ventricular aneurysm.
of
angiographically
proven
posterolateral left ventricular false aneurysm is presented. The patient undersuccessful surgery. The echocardiogram revealed large echo-free went
posterior wall of the left ventricle, delineated by pericardial echoes and lined internally by extra echoes. These echocardiographic findings are consistent with false aneurysm containing a clot. This report indicates that in patients with previous infarction spaces behind the
Agop Aintablian, M.D., F.A.C.A. Division of Cardiology Long-Island Jewish-Hillside Medical Ctr. New Hyde Park, NY 11040
Downloaded from ang.sagepub.com at UNIV OF MONTANA on April 3, 2015
Report and Review of the Literature
Agop Aintablian, M.D., F.A.C.A., Robert I. Hamby, M.D., and Jonathan R. Jaffe, M.D., F.A.C.A. NEW HYDE
PARK,
NEW YORK
One of the major complications of myocardial infarction is the development of ventricular aneurysm.1-4 According to the criteria (clinical, angiographic, or pathologic) used by some authors, the incidence of ventricular aneurysm following myocardial infarction varies between 3.8 and 38%.1-4 Postinfarction aneurysms are usually true rather than
Center in September 1976 for further evaluation of the recent onset of compensated congestive heart failure and an abnormal chest x-ray. He was in good health until March 1976, when he had a serious car accident associated with loss of consciousness. Work-up in another hospital failed to reveal any fractures or abnormalities in the chest x-ray or elec-
false,
trocardiogram.
or
they
are
pseudoaneurysms.
Noninvasive condense M-mode echocardiography has been attempted in patients with ventricular aneurysm.5-’ The diagnosis of a pseudoaneurysm utilizing similar methodology is rare. To out
He returned to work and did well until June 1976. At that time, while at work, he experienced a localized retrosternal burning sensation, which recurred intermittently thruughuui the day. He was seen in an emergency room and, because of a normal electrocardiogram, was sent home. The following day, because of the recurrence of this burning sensation, he
knowledge, echocardiographic findings of a posterior wall pseudoaneurysm have been described in only two cases.’-’ Also, Davidson and associates&dquo; recently reported echocardiographic findings in a patient with anterior wall pseudoaneurysm. We are now reporting another case of echocardiographic documentation of angiographically proven posterior wall false aneurysm in a patient who underwent successful surgery.
hospitalized. During the hospitalization, he developed fever and bilateral pleural effusion, was
and
’
.
’
Case Report
.
A to
it
was
noted
that
his elec-
trocardiogram showed evolutionary changes of a true posterior wall myocardial infarction. Despite an extensive work-up, no specific cause was found for the bilateral exudative pleural effusion
68-year-old white man was admitted Long Island Jewish-Hillside Medical
and a fever of 103°F. After 2 weeks the fever subsided, the pleural effusion resolved, and he was discharged with the diagnosis of pericarditis. At that time the cardiac silhouette, on repeat chest x-ray, was within normal limits. After discharge, he did well until 5 weeks before the present admission, when he was admitted to another hospi-
From the Department of Medicine, Division of Cardiology, Long Island Jewish-Hillside Medical Center, New Hyde Park, New York, Queens Hospital Center Affiliation, Jamaica, Queens, and the School of Medicine, Health Sciences Center, State University of New York at Stony Brook, Stony Brook, New York.
284
Downloaded from ang.sagepub.com at UNIV OF MONTANA on April 3, 2015
285
FIG. 1. Posteroanterior chest roentgenogram the left border of the heart, which was
ing from
demonstrating (arrow) a mass bulginterpreted as a probable ventricular
aneurysm.
tal because of the onset of congestive heart failure with ankle edema, hepatomegaly, and bilateral rales. After digitalization and diuresis, it was noted that his chest x-ray now showed an abnormal bulge of the left cardiac border. Right heart catheterization revealed normal
pressures and
globular
a
posterolateral, large,
aneurysm of the left ventricle.
At this
time, he was transferred to our for further evaluation. Upon hospital was he transfer, asymptomatic and on no medication. There was no history of angina pectoris, myocardial infarction, hy-
Downloaded from ang.sagepub.com at UNIV OF MONTANA on April 3, 2015
286 or diabetes mellitus. Physical examination revealed a blood pressure of 120/80 mm Hg and a regular pulse rate of 80 per minute. Cardiac examination revealed the apical impulse within the fifth left intercostal space in the midclavicular line. There were no thrills, murmurs, or rubs, except for a prominent S4 gallop. There was no ankle edema, hepatomegaly, or neck vein distention. The rest of the physical examination was normal. An admission chest x-ray (Figure 1 ) showed a bulge on the left cardiac border, which, on a lateral x-ray, appeared to be contiguous to the left ventricle. The electrocardiogram revealed normal sinus rhythm, with tall R waves in leads VI to V3, suggesting a dorsal myocardial in-
pertension,
farction. Laboratory data, including urinalysis, routine blood tests, enzyme studies, serum lipid profiles, as well as a 3hour glucose tolerance test, were all normal. On September 9, 1976, a complete right and left cardiac catheterization and coronary angiograms were performed. They revealed slight elevation of the right heart, pulmonary wedge, and left ventricular end-diastolic pressures. Left
ventricular angiograms, performed in the RAO, LAO, and AP projections, showed normal left ventricular wall motion with a large ventricular aneurysm on the posterolateral aspect of the left ventricle (Figure 2). Selective coronary angiograms demonstrated an isolated, complete cutoff of the circumflex artery,
FIG. 2.Levophase of a pulmonary angiogram in the right anterior oblique (A and B) and left anterior oblique (C and D) projections during end-diastole and end-systole. The arrow points to the left ventricular false aneurysm, which seems to expand during systole (B and D).
Downloaded from ang.sagepub.com at UNIV OF MONTANA on April 3, 2015
287
FIG. 3. Condense M-mode echocardiographic scan demonstrating a normal-sized left ventricular chamber with good septal and posterior wall motion. Behind the left ventricular posterior wall, extending from the atrioventricular junction up to the apex, there is an echo-free space (EFS) lined internally by a few extra echoes consistent with a thrombus. Posteriorly, the echo-free space is delineated by pericardial echoes (thin arrows), which, during systole, move in directions opposite to the left ventricular posterior wall.
with normal right anterior descending coronary artery, and 40-50% proximal stenosis of the left anterior descending coronary artery. The echocardiographic examination
carried out with a commercially available Eckoline 20A Ultrasonoscope connected to a Honeywell strip chart recorder and 2.25 mHz, 0.75 inch diameter transducer focused at 7.5 cm. With the patient in a slight left lateral decubitus position, echocardiograms of the aortic and mitral valves were recorded from the fourth intercostal space in the parasternal area, first by identifying the anterior leaflet of the mitral valve and then by rotating the transducer superiorly and medially until the aortic root was identified. Once these structures were identified, several condense M-mode scans were taken and, with inferolateral angulation of the ultrasonic beam, echoes were recorded from the left ventricular was
chamber and the apex. At times, apical echoes were best recorded with the patient in a supine position rather than in a slight left lateral decubitus position. An echocardiographic study performed at this time revealed (Figure 3) a normal-sized left atrium, left ventricle, and right ventricle, with good septal and posterior wall motion. Behind the left ventricular posterior wall, there was a large echo-free space (EFS) delineated by the pericardium and containing a cluster of extra echoes. Since the echofree space did not extend behind the apex and only the pericardium formed the posterior wall of the echo-free space, we diagnosed a pseudoaneurysm of the posterior wall of the left ventricle, rather than a loculated pericardial effusion. The patient underwent left ventricular
aneurysmectomy, which, according
to
the surgical note, measured 8-9 cm on the posterior aspect of the left ventricle,
Downloaded from ang.sagepub.com at UNIV OF MONTANA on April 3, 2015
288 with an opening of 4 cm. It was densely adherent to the pericardium, with an extremely thin free wall paradoxically bulging out during systole. A fair amount of scarring of the surrounding muscle was noted, and inside the aneurysmal sac there was a small amount of laminated thrombus. The pathology report revealed a dense layer of fibrous tissue, with the epicardial surface showing mesothelial proliferation, diagnostic of a false aneurysm with a mural thrombus and chronic pericarditis. After an uneventful postoperative course, the patient was discharged on digoxin. Two months after discharge, he continued to do well with no restriction of his activities.
Discussion The distinction between left ventricular true and false aneurysm is based on pathologic and angiographic findings. In a true aneurysm, the aneurysmal wall is formed by infarcted myocardial tissue containing, primarily, fibrous tissue, among which elements of the ventricular wall may be identified.&dquo; Gradual bulging of this segment will result in a widemouthed aneurysm, whereas in a false aneurysm, which results from an organized hematoma secondary to rupture of the heart, the wall contains fibrous tissue, and no elements of the cardiac wall are retained by the pericardium. A false aneurysm typically has a narrow mouth, which can be identified angiographically to distinguish it from a true aneurysm. Both true and false ventricular aneurysms contain mural thrombi.1O-12 Except for rupture of the heart, patients with true or false left ventricular aneurysm have essentially similar clinical manifestations.7,8,13 Antemortem angiographic documentation of false aneurysm is very rare, since chronic false aneurysm has the potential for rupture.10,13 Although true aneurysm may, on rare oc-
casion, rupture in the early stages of aneurysmal formation, once the fibrous the potential for rupture is small.lo,l3 extremely To our knowledge, only five cases of left ventricular false aneurysm have been
stage is
over,
diagnosed angiographically, 13-16 and one by radioisotope-gated cardiac blood pool imaging.17 Echocardiographic features of left ventricular posterior wall false aneuysm have been reported only twice.8,g Our patient demonstrated an echofree space posterior to the left ventricular wall, the outer contour of which was formed by the pericardium and was lined internally by extra echoes corresponding to a laminated thrombus. It should be mentioned that in this case echo-free space did not extend around the apex of the left ventricle, which distinguishes it from a massive and nonloculated pericardial effusion. Although a loculated,
large pericardial effusion, posterior mediastinal cyst, or pericardial tumor&dquo; cannot be
ruled out
on
the basis of these
echocardiographic findings, considering the overall clinical presentation of this patient with an abnormal bulge on his chest x-ray and paradoxical motion of posterior pericardium, there is no doubt that the diagnosis of pseudoaneurysm of the left ventricular posterior wall was more appropriate than a diagnosis of loculated pericardial effusion. We conclude that a condense M-mode echocardiographic scan is a valuable noninvasive tool, which can be useful in diagnosing ventricular true and false aneurysms. It is our opinion that the condense M-mode echocardiographic scan should be used in all patients who, after myocardial infarction, develop cardiomegaly with recurrent ventricular tachyarrhythmias, congestive heart failure,
unexplained
murmur, or recurrent
hypo-
tension with distorted cardiac silhouette-features that suggest ventricu-
Downloaded from ang.sagepub.com at UNIV OF MONTANA on April 3, 2015
289 lar true or false aneurysm or subacute cardiac rupture. Since patients with false aneurysm and subacute cardiac rupture are amenable to successful surgery, bedside echocardiography in the coronary care unit may help detect these patients, who otherwise may die if these diagnoses are missed or prompt angiographic confirmation and surgery are not performed.
Summary A
case
and distorted cardiac silhouette, echocardiography may be helpful in the diagnosis of true or false ventricular aneurysm.
of
angiographically
proven
posterolateral left ventricular false aneurysm is presented. The patient undersuccessful surgery. The echocardiogram revealed large echo-free went
posterior wall of the left ventricle, delineated by pericardial echoes and lined internally by extra echoes. These echocardiographic findings are consistent with false aneurysm containing a clot. This report indicates that in patients with previous infarction spaces behind the
Agop Aintablian, M.D., F.A.C.A. Division of Cardiology Long-Island Jewish-Hillside Medical Ctr. New Hyde Park, NY 11040
Downloaded from ang.sagepub.com at UNIV OF MONTANA on April 3, 2015
