Left Ventricular Postinfarction Pseudoaneurysm: Diagnostic Advantages of Three-Dimensional Echocardiography.

We present a case of posterior left ventricular pseudoaneurysm, a rare but potentially lethal complication of inferior acute myocardial infarction. The clinical findings and the customary, noninvasive diagnostic methods used are illustrated. Particularly, the most evident display obtained by the employment of three-dimensional echocardiography in comparison to those supplied by two-dimensional ultrasonic method was illustrated.

Introduction

Left ventricular pseudoaneurysm (LVP) is a noncommon complication of myocardial infarction (MI). Other less frequent causes include mitral valve surgery, bacterial endocarditis, and previous chest trauma.[1] Its formation is consequent to the incomplete rupture of the myocardial free wall contained by adherent pericardium or scar tissue.[2] LVPs are characterized by a narrow neck and a large external sac.[3] Its noninvasive diagnosis can be easily obtained by transthoracic echocardiography or magnetic resonance imaging (MRI),[45] left ventriculography is the most accurate diagnostic method but requires an invasive procedure.[6]

We refer on a patient who presented an LVP occurred as a consequence of an inferior MI and evaluated with both traditional, noninvasive methods and three-dimensional echocardiography (3D-E). Three-dimensional echocardiography findings add adjunctive and more accurate informations about LV pseudo-aneurysm respect to those of two-dimensional echocardiography

Case Report

A 79-year-old nondiabetic man joined to the Emergency Department complaining chest discomfort and pulmonary congestion, restlessness, perspiration, and anxiety. Physical examination evidenced the arterial pressure of 115/75 mmHg and the heart rate of 72 beats × min. Electrocardiogram (ECG) showed S-T segment elevation in leads III and aVF and Q waves in leads II, III, and aVF [Figure 1]. At two-dimensional echocardiography (2D-E), decreased LV systolic function (ejection fraction of 40%) with akinesia of the inferior septum and posterolateral wall, was evident. Emergency coronarography immediately performed showed an occlusion of right and circumflex coronary arteries. Immediately, the patient was submitted to two-stent implantation in the same arteries. Four weeks after the percutaneous angioplasty, he presented dyspnea, weakness, and stertors in both pulmonary bases. A mild systolic murmur was heard on left lower sternal border. The continuity of the myocardium at the posterior wall was disrupted and a narrow neck communicating with a small sac was seen at repeated 2D-E [Figure 2]. Cardiac MRI also pointed out a small dilation with a narrow neck in the posterior wall of the LV [Figure 3]. 3D-E was also performed. A full volume acquisition was obtained during held respiration and volume of LVP acquired at end-diastole was of 59.3 mL [Figure 4]. Subsequently, the patient was submitted to surgical treatment of LVP as recommended.[7]

Figure 1

The 12-lead electrocardiogram shows ST elevation and Q waves in inferior derivations (DIII and aVF) and negative T in lateral derivations.

Figure 2

Two-dimensional echocardiography shows the pseudoaneurysm (Ps.) and its neck interesting the left ventricular inferior wall.

Figure 3

Magnetic resonance imaging showing the pseudoaneurysm of left ventricular inferior wall.

Figure 4

Three-dimensional echocardiography reconstruction of left ventricular including the pseudoaneurysm.

Discussion

LVP is a quite rare complication of previous acute coronary syndrome. It was been primarily found in the posteroinferior wall and in basal segments of LV myocardium while less frequently occurs in the anterior LV wall.[6] The most common clinical presentation is dyspnea or congestive heart failure. In other cases, LVP may be characterized by chest pain without further changes of ECG.[8] The classic auscultatory sign of LVP is now systolic murmur reported to mitral regurgitation. 2D-E is a valuable, noninvasive tool for its clinical diagnosis.[9] MRI is an effective diagnostic method to confirm the presence of an aneurysmal dilation and disruption of the epicardial layer.[10] 3D-E is able to define the size and shape of LVP, making easier to evaluate its dimensions, the visualization of diastolic volume, and the neck identification.[11] In addition, this noninvasive method is more useful in its presurgical assessment and for diastolic volume evaluation of LVP. Conclusively, 3D-E is able to add further and more useful informations on LVP respect to those supplied by conventional, noninvasive methods.

Conclusion

The non-invasive diagnosis of LV psudoaneurysm is difficult. In this appraisal, 3D-E appears as a more useful and less time-consuming in comparison with 2D-E, in order to evaluate LV size and shape, its global function and the extension of myocardial scar.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.