Author + information
- Pratik Patel, MDa,∗ (, )
- Michael Siegenthaler, MDb,
- W. Patricia Bandettini, MDc,
- Andrew E. Arai, MDa and
- Kana Fujikura, MD, PhDa
- aAdvanced Cardiovascular Imaging Laboratory, National Heart, Lung and Blood Institute, National Institutes of Health, Department of Health and Human Services, Bethesda, Maryland
- bDivision of Cardiothoracic Surgery, Suburban Hospital, Bethesda, Maryland
- cNational Heart, Lung and Blood Institute, National Institutes of Health, Department of Health and Human Services, Bethesda, Maryland
- ↵∗Address for correspondence:
Dr. Pratik Patel, Advanced Cardiovascular Imaging Laboratory, National Institutes of Health, 10 Center Drive, Bethesda, Maryland 20814.
Left ventricular pseudoaneurysm is a potentially life-threatening complication of acute myocardial infarction. Timely diagnosis is crucial to improve the patient’s prognosis. We describe a multimodality diagnostic approach with emphasis on cardiac magnetic resonance imaging for a left ventricular pseudoaneurysm found surreptitiously in 72-year-old man 2 weeks following an acute myocardial infarction. (Level of Difficulty: Beginner.)
A 72-year-old man with a history of an anterior ST-segment elevation myocardial infarction 16 days before presented to the emergency department with chest pain.
An electrocardiogram and serial troponins were unremarkable. A chest computed tomography angiogram excluded pulmonary embolism. However, it showed a focal aneurysm along the apical lateral wall of the left ventricle (LV) (Supplemental Figure 1) suggestive of pseudoaneurysm or a true aneurysm. An echocardiogram showed no apparent focal outpouching of the LV. Cardiac magnetic resonance imaging (CMR) was obtained to clarify the diagnosis. The CMR images demonstrated an aneurysmal apex with a relatively broad neck. However, there was an abrupt transition of myocardium from normal thickness to a thin layer, compatible with pseudoaneurysm (Figure 1, Videos 1, 2, 3, and 4). Late gadolinium enhancement (LGE) imaging showed a myocardial infarction in the territory of the left anterior descending coronary artery and enhancement in the pericardium that continued to form a thin wall constraining the defect (Figure 1). The pseudoaneurysm also had 3 thrombi (Figure 1, Video 5). There was a large circumferential pericardial effusion with fibrinious standards, likely hemorrhagic on the basis of the parametric T1 mapping (Figure 1, Supplemental Figure 1).
The patient was urgently taken to surgical repair. Intraoperative findings were consistent with LV apical pseudoaneurysm with a contained free wall rupture (Supplemental Figure 2, Video 6). To date, 8.5 months after the surgery, the patient is doing well without any subsequent myocardial infarction, heart failure, stroke, or fatal arrhythmia.
It is important to diagnose pseudoaneurysm early due to the risk of rupture. A echocardiogram is the first-line imaging modality to assess for pseudoaneurysm. It can usually differentiate pseudoaneurysm from a true aneurysm by demonstrating a narrow neck and an abrupt break in the myocardium. However, the echocardiogram is limited by technical skill level during image acquisition, the patient’s body habitus, and sometimes suboptimal echocardiographic windows. Computed tomography allows for a comprehensive assessment of a cardiac structure in any desired axes. CMR has further advantages due to lack of ionizing radiation or iodinated contrast and providing information on tissue characteristics such as presence and extent of myocardial infarction and pericardial inflammation.
By visualizing an aneurysmal area from any desirable angle, CMR allows for a complete delineation of the anatomy including seeing the abrupt break in the myocardium. A narrow neck can be assessed by calculating the ratio of diameters of the neck and the outpouching body (1). Furthermore, pericardial enhancement on LGE imaging is commonly seen in pseudoaneurysm because of pericardial inflammation (1). Hemorrhagic pericardial effusion can be assessed with parametric T1 mapping.
The authors have reported that they have no relationships relevant to the contents of this paper to disclose.
The authors attest they are in compliance with human studies committees and animal welfare regulations of the authors’ institutions and Food and Drug Administration guidelines, including patient consent where appropriate. For more information, visit the JACC: Case Reports author instructions page.
- Abbreviations and Acronyms
- cardiac magnetic resonance
- late gadolinium enhancement
- left ventricle
- Received May 1, 2020.
- Accepted May 13, 2020.