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Number 10-10 The Woman with Three Ventricles: a case of left ventricular aneurysm with thrombus
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Number 10-10  The Woman with Three Ventricles: a case of left ventricular aneurysm with thrombus

Case from: Patrizia Pedrotti1, Alberto Barosi2, Angela Milazzo1, and Alberto Roghi1
Insutitutions:  Cardiovascular Magnetic Resonance Unit1 and Cardiosurgery Unit2, De Gasperis Department of Cardiology, Ospedale Niguarda Ca’Granda Milano, Italy 

Clinical history: A 78 year old woman with unremarkable past medical history was admitted to the hospital because of left sided paralysis caused by an embolic stroke.  ECG on admission showed sinus rhythm and inferior Q-waves suggestive of remote myocardial infarction.

 

 

Movie 1

 

Transthoracic echocardiogram showed a large aneurysm on the inferior basal wall of the left ventricle with preserved left ventricular global function (Movie 1).

 

 

Movie 2

 

 

Short axis legend

 

CMR was performed on a 1.5T scanner (Siemens Avanto).  SSFP cine images showed a large aneurysm (the "third ventricle") of the inferior basal wall of the left ventricle (depth 47 mm, transversal diameter 57 mm, neck 30 mm, volume 43 ml); the inferolateral papillary muscle was not involved and only mild mitral regurgitation was detected (Movie 2).  Left ventricular ejection fraction was 55% and 38% with exclusion and inclusion of the aneurysm, respectively.  Contractility of the left ventricular segments were normal.

 

   

Image 1                               Image 2

 

Early inversion recovery imaging following the administration of gadolinium (Magnevist, 0.15 mmoles/kg) showed extensive mural thrombus within the aneurysm (Area of signal void noted by red arrows on images 1 and 2).  The thrombus was not seen on the transthoracic echocardiogram partially due to lower spatial resolution in the far field.  The mural thrombus was determined to be the source of the patient's embolic event.

 

    

Image 3                               Image 4

 

Late enhancement imaging clearly depicted the collection of gadolinium, therefore signal enhancement, within the fibrotic walls of the aneurysm (red arrows, images 3 and 4).  No other areas of myocardial late enhancement were detected. 

Follow up:  The patient underwent aneurysmectomy.  Coronary anatomy was not suitable for bypass grafting due to significantly calcified coronary arteries.  Post operative course was uneventful and optimal surgical result was documented by echo which showed preserved left ventricular function and only mild mitral regurgitation.

Perspective:  Though the echocardiogram initially identified the LV aneurysm (LVA), CMR more clearly defined the LVA extension, volume, relationship with the papillary muscle and mitral valve plane, and myocardial viability, thus guiding the planning of surgical aneurysmectomy.  This case went on to demonstrate mural thrombus within the aneurysm utilizing early inversion recovery imaging soon after the administration of gadolinium as well as extensive fibrosis on late enhancement sequences.1,2

CMR was helpful in distinguishing this acquired post-infarction aneurysm from congenital LV aneurysm, which more frequently involves the LV apex, typically in the absence of obstructive coronary artery disease and with variable ECG findings.3,4

 

References: 

1. Heartlie GJ, Mohiaddin R.  Left ventricular aneurysm: comprehensive assessment of morphology, structure and thrombus using cardiovascular magnetic resonance.  Clin Radiol 2005;60:687.

2. Garcia Fuster R, Estornell J, Hornero F, Montero JA.  True versus false ventricular aneurysm: accurate diagnosis with gadolinium magnetic resonance.  Ann Thor Surg 2005;80:1528.

3. McMahon J, Moniotte S, Powell AJ, Del Nido PJ, Geva T.  Usefulness of magnetic resonance imaging evaluation of congenital left ventricular aneurysms.  Am J Cardiol 2007;100:310.

4. Ohlow MA, Lauer B, Geller JC. Prevalence and spectrum of abnormal electrocardiograms in patients with an isolated congenital left ventricular aneurysm or diverticulum. Europace 2009;11:1689-95.


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COTW handling editor: Kevin Steel

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