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(Circulation. 2002;105:e51.)
© 2002 American Heart Association, Inc.

Images in Cardiovascular Medicine

Left Ventricular Apical Pseudoaneurysm

Echocardiographic and Intraoperative Findings

Jason H. Rogers, MD; Nilto C. De Oliveira, MD; Ralph J. Damiano, Jr, MD; Joseph G. Rogers, MD

From the Divisions of Cardiovascular Medicine (J.H.R., J.G.R.) and Cardiothoracic Surgery (N.C.D.O., R.J.D.), Washington University School of Medicine, St Louis, Mo.

Correspondence to Joseph G. Rogers, MD, Division of Cardiovascular Medicine, Washington University School of Medicine, 660 South Euclid, Box 8086, St Louis, MO 63110. E-mail jrogers{at}im.wustl.edu

A 57-year-old man with a history of hypertension and tobacco use was emergently transferred to our facility for management of a myocardial rupture. Three weeks before transfer, the patient had experienced an episode of chest pain, dyspnea, diaphoresis, and near syncope. After evaluation at an outside facility, the patient was sent home with a provisional diagnosis of pleurisy. Blood cultures drawn at that time later grew peptostreptococcus, and the patient was admitted to an outside hospital for intravenous antibiotics. An echocardiogram was performed to rule out endocarditis. Echocardiography demonstrated a large apical myocardial rupture and apical pseudoaneurysm, which contained a large amount of thrombus (Figures 1A and 1B and the Movies, which are available in an online-only Data Supplement at http://www.circulationaha.org). Coronary angiography revealed an ulcerated plaque in the mid-left anterior descending artery without significant disease in the other vessels. The patient underwent emergent surgical repair at which time a friable clot was found within the pseudoaneurysm (Figure 2A). The repair was accomplished by the endoventricular circular patch plasty technique ("Dor procedure") (Figure 2B). Surgical pathology of the excised specimen showed organizing hematoma with fragments of thin fibrous membrane, consistent with a pseudoaneurysm. The patient did well during the postoperative period, but died from a fatal cardiac arrhythmia on postoperative day 10.

View larger version (90K): [in this window] [in a new window]   Figure 1. Transthoracic echocardiography of apical pseudoaneurysm. A, Apical 4-chamber view demonstrates large apical pseudoaneurysm containing a large thrombus (asterisk). There is a sharp discontinuity of the myocardium at the site of the pseudoaneurysm communication with the left ventricular cavity (arrows). B, Apical 4-chamber view with Optison enhancement of the left-ventricular cavity (Op), showing clear delineation of thrombus within the pseudoaneurysm (asterisk).

View larger version (98K): [in this window] [in a new window]   Figure 2. Intraoperative appearance of apical pseudoaneurysm. A, Note large amount of friable clot contained within the pseudoaneurysm. B, Repaired pseudoaneurysm by the endoventricular circular patch plasty technique. A patch of bovine pericardium was used (arrowheads), restoring a more normal geometry to the left ventricle.

Footnotes

Movies I and II are cine loops and are available in an online-only Data Supplement at http://www.circulationaha.org

The editor of Images in Cardiovascular Medicine is Hugh A. McAllister, Jr, MD, Chief, Department of Pathology, St Luke’s Episcopal Hospital and Texas Heart Institute, and Clinical Professor of Pathology, University of Texas Medical School and Baylor College of Medicine.

Circulation encourages readers to submit cardiovascular images to the Circulation Editorial Office, St Luke’s Episcopal Hospital/Texas Heart Institute, 6720 Bertner Ave, MC1-267, Houston, TX 77030.

This Article Extract Full Text (PDF) Data Supplement Alert me when this article is cited Alert me if a correction is posted Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Download to citation manager Request Permissions Citing Articles Citing Articles via Google Scholar Google Scholar Articles by Rogers, J. H. Articles by Rogers, J. G. Search for Related Content PubMed PubMed Citation Articles by Rogers, J. H. Articles by Rogers, J. G. Related Collections Echocardiography CV surgery: other Acute myocardial infarction