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Ann Thorac Surg 1997;64:830-831
© 1997 The Society of Thoracic Surgeons

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Case Report

Posttraumatic Left Ventricular Pseudoaneurysm Due to Intramyocardial Dissecting Hematoma

Department of Cardiac Surgery, Ospedale Maggiore della Carità, Novara, Italy

Accepted for publication March 29, 1997.

	Abstract

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A left ventricular aneurysm can develop in patients sustaining blunt chest injury. This condition has been attributed to myocardial contusion or to a direct vascular lesion leading to myocardial necrosis. We report the case of a pseudoaneurysm resulting from myocardial dissection beginning from a small tear in the endocardial wall. Successful surgical exclusion of the pseudoaneurysm by endoaneurysmal patch closure of the communications between the aneurysm and the left ventricular cavity is described.

	Introduction

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An 18-year-old man had a motorcycle accident with multiple fractures of the left arm and leg, blunt chest trauma, and abdominal trauma necessitating an explorative laparotomy and splenectomy. The electrocardiogram was normal and the serum levels of the myocardial-specific isoenzyme of creatine kinase were within normal limits.

He was referred to our institution 7 months later, when a routine chest roentgenogram showed a semicircular protuberance in the left inferior arch of the cardiac silhouette. Admission physical examination revealed an asymptomatic young man. Blood pressure was 120/80 mm Hg, heart rate was 70 beats/min, and no cardiac murmurs were noted. Two-dimensional echocardiography revealed the presence of a 3.5 x 4-cm cavity communicating with the left ventricle by a small defect in the anterobasal wall, which was first interpreted as a ventricular rupture contained by pericardial sac. However, a second examination of the images showed that the myocardial wall on both sides of the "neck" of the aneurysm was divided to form a sort of double Y. The two external Y branches joined to form the epicardial wall of the aneurysm, and the two Y branches closer to the left ventricular cavity joined to form a sort of diaphragm separating the left ventricular cavity from the aneurysm. Two small defects in the middle of the diaphragm allowed communication between the two cavities. A new transthoracic and transesophageal echocardiography confirmed these impressions (Fig 1). The coronary angiography showed normal coronary arteries, with a patent left anterior descending artery curving smoothly around the base of the aneurysm. Left ventriculography confirmed the presence of a pseudoaneurysm.

View larger version (109K): [in this window] [in a new window]   Fig 1. . Transthoracic echocardiography: parasternal short-axis view of the left ventricle (VS) at the level of the tips of the mitral leaflets (PAP) showing the aneurysm (between the two small crosses) communicating via a small hole, pointed out by three arrows, with the left ventricular cavity. Note the diaphragm separating the two cavities and the Y shape of the myocardial wall at the base of the aneurysm.

View larger version (165K): [in this window] [in a new window]   Fig 2. . Intraoperative view: the pseudoaneurysm is entered and its interior is seen. The head of the patient is at the base of the picture. Two holes are visible in the diaphragm separating the left ventricle from the pseudoaneurysm.

	Comment

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Traumatic left ventricular aneurysm is an uncommon complication of blunt chest trauma. In 1989 Grieco and associates [1] reported a literature review in which 32 cases were analyzed and 3 further cases added. Grieco and associates suggested the possibility that the real cause of aneurysm formation after blunt chest injury is not a contusion of the myocardial wall as previously thought but a vascular lesion, involving the left anterior descending artery, leading to ischemic necrosis. A third mechanism involved in aneurysm formation after blunt chest injury may be an intramyocardial dissection resulting in pseudoaneurysm formation.

Intramyocardial dissecting hematoma as a complication of myocardial infarction has already been reported [2], and we believe that, in the single case we report, a myocardial dissection originating from a small tear in the endocardial wall of the anterior myocardium was responsible for pseudoaneurysm formation. The left anterior descending artery was patent and, even if a recanalization can be hypothesized, there was no suggestion of myocardial necrosis at the time of trauma. The lesion was very localized and the pathologic findings strongly supported a myocardial dissection because of the presence of a nearly complete diaphragm separating the aneurysm from the ventricular cavity. Our patient was asymptomatic, and his clinical course confirms that electrocardiography and the myocardial-specific isoenzyme of creatine kinase are poor indicators of traumatic myocardial injuries [3]. At present, even if the electrocardiogram and the level of the myocardial-specific isoenzyme of creatine kinase are within normal limits, we perform a transthoracic echocardiography as a routine procedure in patients suffering blunt chest trauma at the time of first observation and every 3 months for the first year. Echocardiography in this case was the key to a correct understanding of the mechanism of the lesion and was very helpful in planning the correct treatment. With regard to the surgical technique, the endoaneurysmal patch closure of the neck of the aneurysm was preferred to mattress pledgeted sutures to avoid any damage to the left anterior descending artery, which was very close to the medial border of the aneurysm itself. Probably a patch closure in the cases like the one we report, given the particular cause of the lesion, is more recommended to preserve the correct shape and function of the left ventricle.

	Footnotes

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Address reprint requests to Dr Maselli, Divisione di Cardiochirurgia, Ospedale Maggiore della Carità, Corso Mazzini 18, Novara 28100, Italy.

	References

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1. Grieco JG, Montoya A, Sullivan HJ, et al. Ventricular aneurysm due to blunt chest injury. Ann Thorac Surg 1989;47:322–9.[Abstract/Free Full Text]
2. Pliam MB, Sternlieb JJ. Intramyocardial dissecting hematoma: an unusual form of subacute cardiac rupture. J Card Surg 1993;8:628–37.[Medline]
3. Harley DP, Mena I, Narahara KA, Miranda R, Nelson RJ. Traumatic myocardial dysfunction. J Thorac Cardiovasc Surg 1984;87:386–93.[Abstract]

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This Article Abstract Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Daniele Maselli Carlo De Gasperis Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Maselli, D. Articles by De Gasperis, C. Search for Related Content PubMed PubMed Citation Articles by Maselli, D. Articles by De Gasperis, C.