Left Ventricular Apical Pseudoaneurysm
Echocardiographic and Intraoperative Findings
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.
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.
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