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Number 09-02: Giant LV Pseudoaneurysm by CMR
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Number 09-02: Giant LV Pseudoaneurysm by CMR

Case from: Christian Hamilton-Craig, Richard E Slaughter, Mark Hansen, Centre for Cardiovascular MRI, The Prince Charles Hospital, Brisbane, Australia.

History: 79 year old male with late-presentation lateral STEMI 3days earlier. Coronary angiography revealed culprit thrombotic occlusion of a large OM3 branch and an 80% stenosis in the proximal LAD. Bare metal stenting of the OM3 resulted in no-reflow (figure A). The patient discharged himself against medical advice. He represented 7 days later in acute heart failure.

Echo: EF 30%, moderate aortic stenosis, akinetic lateral wall which was poorly defined (figure B). Cardiac MRI was therefore performed to further assess structure and viability.

 

    

 

CMR: Steady state free precession (GE Twinspeed 1.5 Tesla) revealed a giant left ventricular lateral wall pseudoaneurysm (cine movies C,D) Delayed gadolinium enhancement images confirmed rupture of the lateral free wall, contained by a thin layer of visceral pericardium, thereby differentiating pseudoaneurysm from true aneurysm (figures E,F).  The LAD territory was viable. Urgent surgery was performed that day, with successful pseudoaneuyrsm repair (Dor procedure) +CABG and AVR.

Discussion: CMR is superior to echocardiography for the assessment of left ventricular structural abnormalities. Delayed enhancement imaging allows assessment of viability, presence of thrombus, and identification of aneurysm/pseudoaneurysm.  Patients with left ventricular pseudoaneurysm have a 30-45% risk of rupture, with very high mortality [1-3].  Mircrovascular obstruction due to the no-reflow phenomenon may have contributed to the lateral wall rupture in this case. Identification of pseudoaneurysm by CMR allowed for timely intervention, which may otherwise have been missed.

1. Frances C. Romero A. Grady D. Left ventricular pseudoaneurysm [Review]. J Am Coll Cardiol. 32(3):557-61, 1998 Sep.
2. Vlodaver, Z; Coe, J.L; Edwards, J.E.  True and false left ventricular aneurysms: Propensity for the latter to rupture.  Circulation. 1975; 51: 567-572
3. Davutoglu, V; Soydinc, S; Sezen, Y; Aksoy, M.  Unruptured giant left ventricular pseudoaneurysm complicating silent myocardial infarction in a diabetic young adult.  Int J CV Imaging.  2005; 21: 231-234.

 


    

    

 

Discussion: CMR is superior to echocardiography for the assessment of left ventricular structural abnormalities. Delayed enhancement imaging allows assessment of viability, presence of thrombus, and identification of aneurysm/pseudoaneurysm.  Patients with left ventricular pseudoaneurysm have a 30-45% risk of further rupture, with very high mortality [1-3].  Mircrovascular obstruction due to the no-reflow phenomenon may have contributed to the lateral wall rupture in this case. Identification of pseudoaneurysm by CMR allowed for timely intervention, which may otherwise have been missed.


1. Frances C. Romero A. Grady D. Left ventricular pseudoaneurysm [Review]. J Am Coll Cardiol. 32(3):557-61, 1998 Sep.
2. Vlodaver, Z; Coe, J.L; Edwards, J.E.  True and false left ventricular aneurysms: Propensity for the latter to rupture.  Circulation. 1975; 51: 567-572
3. Davutoglu, V; Soydinc, S; Sezen, Y; Aksoy, M.  Unruptured giant left ventricular pseudoaneurysm complicating silent myocardial infarction in a diabetic young adult.  Int J CV Imaging.  2005; 21: 231-234.

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