Left Ventricular Pseudoaneurysm
Echocardiographic and Intraoperative Images
A 44-year-old hypertensive woman with fever for 1 week and a history of apical myocardial infarction (1 month before) was transferred to our institution with chest pain and dyspnea. On physical examination, her heart rate was 115 bpm, her arterial blood pressure was 85/50 mm Hg, and peripheral cyanosis was present. The ECG showed sinus tachycardia and Q waves in the V1 to V2 leads. The serum concentrations of creatine phosphokinase-MB, troponin I, and myoglobin were within normal limits. A chest x-ray revealed an enlarged heart and a mild left pleural effusion. Two-dimensional transthoracic echocardiography (TTE) showed a large apical ventricular discontinuity (widest diameter 2.82 cm; Figure 1a) in communication with an echo-free space, suggestive of a huge pseudoaneurysm with a partially stratified thrombus (Figure 1b). A minimal pericardial effu-sion was present. The maximum internal end-systolic pseudoaneurysmal diameters were 11.27×10.45 cm (Figure 2a) with a ratio of orifice to cavity diameter of 0.25. Color Doppler showed flow passage from the left ventricle into the pseudoaneurysm (Figure 2b) and pulsed Doppler demonstrated systodiastolic flow through the false aneurysmal mouth (Figure 3a). Coronary angiography revealed a midportion occlusion of the left anterior descending artery; ventricular angiography was not performed because of the high risk of pseudoaneurysmal rupture. Surgery confirmed the diagnosis (Figure 3b), and the myocardial hole was repaired via endoventricular circular patch plasty. The postoperative course was uneventful.