Central picture legend. Contrast-enhanced MRI, demonstrating the giant
left ventricular inferior wall aneurysm.
Central message
Inferior wall postinfarction aneurysms are found infrequently and can
have unusual forms. Cardiac MRI should be done to guide surgical
intervention.
Abstract
Background. Ventricular aneurysms develop after transmural
myocardial infarctions and can significantly worsen clinical outcomes.
We report an unusual case of the giant inferior wall aneurysm,
successfully treated by surgical resection.
Case presentation. The 65-year-old male was diagnosed with a
giant inferior wall left ventricular aneurysm after worsening of his
dyspnoea. Four months prior to the admission, he had ST-elevation
inferior myocardial infarction, complicated by pericarditis. During the
4-month follow-up period, the aneurysm has significantly increased in
size. Unrecognized ventricular wall rupture was supposed. The precise
anatomy of the aneurysm was established by cardiac MRI. Surgical
resection of the aneurysm was performed with uneventful patient’s
recovery.
Conclusion. Timely surgical treatment of the rapidly growing
aneurysms is recommended. In such cases cardiac MRI can specify anatomy
and coordinate surgical strategy.
Background
Ventricular aneurysms occur after full-thickness myocardial infarctions
(MI) in 30-35 %. They contribute to the development of systolic
myocardial dysfunction thus reducing survival rates. Most aneurysms are
true aneurysms and more typically occur at the apical part of the LV
wall [1]. Basal aneurysms are usually false, their incidence is
relatively rare and varies between 5 and 10% [1-3]. Timely surgical
intervention upon diagnosis established is recommended, considering that
inferior wall aneurysms have significant potential for rupture [4].
Case presentation
65-year-old patient admitted to the hospital with worsening fatigue and
shortness of breath within last 3 weeks (chronic heart failure NYHA
class III). He had an acute inferior ST-elevation myocardial infarction
(MI) four months prior to the admission. Noteworthy, the patient refused
angiography at the time of the initial presentation. The course of MI
was complicated by the basal left ventricular (LV) aneurysm with the
thrombus revealed on transthoracic echocardiography (TTE), followed by
the pericardial effusion, which required pericardiocentesis.
At the current hospitalization, coronary angiography demonstrated
multivessel disease with the right coronary artery occlusion and
transesophageal echocardiography (TEE) revealed the giant inferior wall
aneurysm (Figure 1, A). The aneurysm contained large thrombus and was
surrounded by multiple pericardial adhesions, giving the suspicion of an
unrecognized LV free wall rupture. Other echocardiography findings:
LVEDV – 189 ml, LVEF (Simpson) – 32%, mild to moderate MR. For the
sake of defining the precise LV anatomy, contrast-enhanced MRI scan was
performed, which confirmed the destructed inferior LV wall, replaced
with the giant aneurysm 10.5 cm length and 7.1 cm width (figure 1, B).
According to the available diagnostic findings, this patient was
scheduled for the surgical treatment. Expeditious surgery was carried
out: meticulous cardiolysis with aneurysm mobilization and resection,
followed by the left ventricular reconstruction using elliptical bovine
pericardial patch (figure 2). There was no distal target for the right
coronary artery grafting, therefore single LITA-LAD graft was
additionally performed. Patient’s postoperative course was uneventful,
postoperative TTE showed markedly reduced LVEDV (118 ml) and trace MR.
The patient was discharged home on day 7 with substantial clinical
improvement (NYHA class I). Two-month follow-up MRI scan is demonstrated
on the figure 1, C.
Discussion
Inferior wall aneurysms are rare complications of transmural MI, often
leading to severe systolic dysfunction and increased risk of death [4,
5]. There are two types of aneurysms: true aneurysms, which by
definition have thin, solid, well demarcated, akinetic or dyskinetic
fibrotic wall with no viable myocardium and false aneurysms, which have
narrow connection with LV cavity, have interruptions within muscular
layer on echocardiography and often covered with the thrombus. They
often develop when the patient survives an episode of the ventricular
free wall rupture [5].
It seems that in our case both mechanisms played a role. Upon MI
entailed by the formation of the true basal aneurysm and pericarditis,
dense adhesions surrounding the infarction area eventually developed.
When gradual enlargement of the aneurysm led to the wall perforation,
adhesive process prevented fatal cardiac tamponade, and let the patient
survive this episode. Staged cardiac visualization with transthoracic
echocardiography, cardiac MRI and intraoperative transesophageal
echocardiography provided sufficient anatomic information and
coordinated surgical strategy.
Conclusion
Basal aneurysms are rarely seen, frequently have odd anatomy and can be
poorly visualized on routine echocardiography, thus cardiac MRI can be
useful in the anatomical verification. Expeditious surgical treatment is
recommended for preventing of the aneurysmal rupture and heart failure
progression.
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Figure legends