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Published on: August 16, 2019
Myocardial rupture and left ventricular pseudoaneurysm due to late STEMI presentation during the COVID-19 pandemic
Audra Banisauskaite1,2, Periaswamy Velavan3, Jonathan Hasleton3
1Radiology Department, Liverpool Heart and Chest Hospital NHS Foundation Trust, Thomas Drive, Liverpool L14 3PE, UK.
Insights
A rare left ventricular (LV) pseudoaneurysm following myocardial infarction (MI) progressed despite conservative management. Surgical aneurysmectomy improved LV systolic function in this case.
Area of Science:
- Cardiology
- Cardiac Surgery
- Medical Imaging
Background:
- Left ventricular (LV) pseudoaneurysm is a rare but serious complication of myocardial infarction (MI).
- It arises from a rupture in the injured myocardial wall, contained by surrounding pericardium or scar tissue.
- Often associated with delayed revascularization in MI patients.
Observation:
- A 64-year-old male presented with chest pain, initially misdiagnosed.
- Electrocardiography revealed ST-elevation MI; coronary angiography identified circumflex artery occlusion, treated with angioplasty.
- Cardiovascular magnetic resonance (CMR) showed healed lateral wall rupture with adherent pericardium.
Findings:
- Initial conservative management failed as the pseudoaneurysm significantly progressed over two months.
- Multimodality imaging, including echocardiography and cardiac CT, confirmed pseudoaneurysm progression.
- Surgical aneurysmectomy was performed, leading to symptom resolution and improved LV systolic function on follow-up CMR.
Implications:
- Multimodality imaging is crucial for diagnosing and differentiating LV pseudoaneurysms from true aneurysms.
- Conservative treatment may be ineffective for progressing pseudoaneurysms.
- Aneurysmectomy can be an effective treatment, improving cardiac function in selected cases.
Background:
Left ventricular (LV) pseudoaneurysm is a serious and rare complication of myocardial infarction (MI). It occurs when an injured myocardial wall ruptures and is contained by overlying adherent pericardium or scar tissue, most commonly it develops in patients with late presentation of MI and delayed revascularization.
Case Summary:
A 64-year-old man presented to the emergency department with intermittent central chest pain radiating to back and neck and increasing on deep inspiration, which was considered to be of musculoskeletal origin for a week, but worsened despite medications. Electrocardiography showed features of ST-elevation MI; a circumflex artery occlusion was found on coronary angiogram and angioplasty was performed. Cardiovascular magnetic resonance (CMR) revealed features of healed lateral wall rupture with adherent parietal pericardium and the patient was managed conservatively. Two months later the patient returned with severe chest pain; echocardiogram and cardiac computed tomography showed significant interval progression of the pseudoaneurysm. Aneurysmectomy was performed, after which the patient recovered and had none of the previous symptoms since. Follow-up CMR study revealed improvement of LV systolic function.
Discussion:
A rare case of post-infarction LV pseudoaneurysm was reported. Multimodality imaging helped to detect and to differentiate this complication from the true aneurysm and to follow it up and plan the treatment. Conservative treatment was not effective in this case as the pseudoaneurysm progressed; aneurysmectomy helped to improve LV systolic function.
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