Ann Thorac Surg 1997;64:831-834
© 1997 The Society of Thoracic Surgeons
Case Report
Coincidence of True and False Left Ventricular Aneurysm
Asish Kumar Das, MD,
Geoffrey M. Wilson, MD,
Anthony P. Furnary, MD
Albert Starr Academic Center for Cardiac Surgery, Providence St. Vincent Medical Center, Portland, Oregon
Accepted for publication June 23, 1997.
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Abstract
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Coincidence of true and false left ventricular aneurysm is very rare. To date 6 cases have been reported in the world literature. We present a case of false aneurysm emanating from a posterior true aneurysm of the left ventricle. These findings were demonstrated preoperatively by transesophageal echocardiography and were confirmed at operation. The aneurysms were successfully resected and the ventricle repaired.
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Introduction
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Aneurysms of the left ventricle are of two types: true and false (or "pseudo"). True aneurysms are sequelae of transmural myocardial infarction. They vary widely in size and compliance, infrequently undergo progressive expansion, and seldom rupture. False aneurysms or pseudoaneurysms are rare complications of myocardial infarction or iatrogenic perforation and represent a contained myocardial rupture. A pseudoaneurysm does not contain all the three layers of the myocardium and is frequently lined by pericardium and mural thrombus [1, 2]. In contrast to true left ventricular aneurysms, false aneurysms have a tendency to rupture and, therefore, require expeditious operative management soon after the diagnosis is made, even in asymptomatic patients [3]. Diagnosis of false aneurysms can be suspected in chest radiographs with rapid or progressive expansion of an aneurysm [4]. More definitive diagnosis is achieved by echocardiography, nuclear studies, angiography, or magnetic resonance imaging [5]. Coexistence of true and false aneurysms is extremely rare. To date 6 cases have been reported in the world literature [5]. Another such case is reported here.
A 70-year-old man, 2 months after inferior wall myocardial infarction, presented to an outlying institution with a 4-day history of dyspnea, orthopnea, and paroxysmal nocturnal dyspnea. On admission the patient had clinical evidence of bilateral pleural effusions and congestive heart failure. Cardiac examination revealed normal first and second heart sounds with a gallop. He was treated for heart failure with diuretics for a period of 3 days. The patient continued to have sharp chest pain, and prednisolone administration was started for presumed Dressler's syndrome. His clinical condition improved over the ensuing 4 days. However, on the fifth day a new grade III/VI systolic ejection murmur developed best heard at the apex. Transthoracic echocardiography revealed a large 12.5 x 6-cm basilar mass communicating with the left ventricle. The patient was transferred to our institution with the possible diagnosis of left ventricular rupture after myocardial infarction with hemopericardium. Repeat echocardiography (transesophageal) revealed a large inferoapical pseudoaneurysm emanating from a posterobasilar true aneurysm, which had wide communication with the left ventricle. This communication juxtaposed the mitral annulus superiorly and both papillary muscles anteriorly and posteriorly. There was mild mitral regurgitation. There was a second communication near the apex of the true aneurysm, which led to the pseudoaneurysm. The pseudoaneurysmal sac was large and extended anteriorly where it compressed the right ventricle.
Coronary angiography revealed total occlusion of the right coronary artery with a normal left coronary artery. Left ventriculography (Fig 1
) showed a true inferior wall aneurysmal sac only.
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Fig 1. . (A) Left ventriculogram in diastole. The heart is of normal size. There is no filling defect or outpouching. (B) Left ventriculogram in systole. The heart is of normal contour. There is no evidence of aneurysm. Left ventricular function is good.
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In April 1996 the patient underwent elective operation. Intraoperative transesophageal echocardiography (Fig 2) showed no ventricular septal defects. There was a complex aneurysmal sac, which appeared as a large true posterobasilar left ventricular aneurysm (6 x 8 cm) with a communication to a second loculated sac near the apex. Color Doppler flow (Fig 3) clearly showed the jet into the false aneurysm.
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Fig 2. . Transesophageal two-chamber view demonstrating a large aneurysm of the basal inferior wall (double arrows). A false aneurysm extends toward the apex of the left ventricle.
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Fig 3. . Transesophageal two-chamber view. Color Doppler echocardiography shows a broad jet entering the true aneurysm (double arrow). A narrow color jet originating from the true aneurysm extends into the false aneurysm (single arrow).
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At operation the patient had dense pericardial adhesions. The pseudoaneurysmal sac, which contained thrombus, extended anteriorly over the right ventricle and completely covered the right atrium. Cannulation of the right atrium was initially impossible. Hence, femoral vein cannulation was planned. On exploration both femoral veins were completely thrombosed with fresh and old thrombi. The left femoral vein was cannulated after balloon thrombectomy. Partial cardiopulmonary bypass (flow, 1.5 L/min) was established after standard aortic cannulation. Further dissection of the pseudoaneurysm on the right atrium was carried out. Full cardiopulmonary bypass was established by cannulating the right atrium through the pseudoaneurysm.
Once the aneurysmal complex was opened it was confirmed to be a large true aneurysm posteriorly with a pseudoaneurysm anteriorly. A Hemashield (Meadox Medicals, Oakland, NJ) patch closure of the 4-cm defect into the true left ventricular wall was done. The opening was intimately associated with the base of both papillary muscles and the mitral valve annulus. The patient tolerated the procedure very well and was weaned from cardiopulmonary bypass easily with minimal inotropic support. The patient was discharged from the hospital in good condition on the eighth postoperative day.
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Comment
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Both true and false aneurysms of the heart are complications of myocardial infarction. A true aneurysm results from gradual thinning of the portion of the ventricular wall after transmural infarction. False aneurysms occur after hemorrhagic dissection into an area of transmural infarction and most commonly result in free intrapericardial rupture of the heart, cardiac tamponade, and death. Rarely, if the overlying pericardium becomes adherent to the epicardium along the surface of the infarct, it can contain the rupture. This then becomes a false aneurysm, its wall being lined by pericardium and mural thrombus [1].
The pathogenesis of true and false aneurysms is different. True aneurysms are formed after infarct remodeling, whereas false aneurysms arise from rupture or slow leaks complicating myocardial infarction, occurring in the acute phases and slowly expanding over time [1, 2]. Histologic examination of the resected pseudoaneurysm reveals no evidence of myocardial wall components. Containment of the disrupted myocardium is secured by the pericardium and formation of organized thrombus as the wall of the false aneurysm. This wall has little strength and is very prone to rupture. It is estimated that approximately 20% to 45% of false aneurysms eventually rupture [3]. False aneurysms, therefore, require urgent operative management even in asymptomatic patients [1, 6]. Although false aneurysms most commonly follow myocardial infarction, they may also occur as a sequel to cardiac operations, trauma, or endocarditis [2].
The coincidence of true and false aneurysms is extremely rare [5]. To date 6 cases have been reported in the world literature [4, 5, 7–10] (Table 1). Of 7 cases (including the present case) all were in men ranging in age from 34 to 75 years. The clinical presentation was from 2 months to 7 years after the initial event. In most cases the false aneurysms arose from the anterior and anteroapical regions. One case involved the inferior wall. In the present case the aneurysmal complex arose from the posterobasilar wall. The clinical presentations varied from asymptomatic or incidental findings to progressive heart failure to frank cardiac tamponade.
Diagnosis of the pseudoaneurysms may be made by angiography, computed tomography, magnetic resonance imaging, or two-dimensional echocardiography [7]. In our case the left ventriculography and transthoracic echocardiography did not show any evidence of pseudoaneurysm. However, transesophageal echocardiography clearly demonstrated the presence of a pseudoaneurysm arising from a true left ventricular aneurysm. The appearance of a new systolic ejection murmur at the apex in the absence of a ventricular septal defect or significant mitral regurgitation is an interesting finding. The systolic murmur arising from the blood flow through the neck of a left ventricular pseudoaneurysm has been well described. However, without left ventriculography or transesophageal echocardiography it would probably be impossible to be certain that a systolic murmur in a patient with a ventricular aneurysm was not caused by mitral regurgitation associated with the ventricular dilatation that occurs in the presence of a large true aneurysm [4].
Occasionally these two types of ventricular aneurysms may coexist and pose diagnostic difficulties. Because of the propensity for pseudoaneurysmal rupture, an accurate diagnosis is paramount. Therefore, awareness and vigilance are important for successful surgical resection and repair.
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Acknowledgments
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We appreciate the assistance of Cindy L. Fessler and Natasha Pfeifer in the preparation of the manuscript and figures.
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Footnotes
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Address reprint requests to Dr Furnary, Albert Starr Academic Center, 9155 SW Barnes Rd, Suite 240, Portland, OR 97225.
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References
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- Davidson KH, Parisi AG, Harrington JJ, Barsamian EM, Fishbein MC. Pseudo aneurysm of the left ventricle: an unusual echocardiographic presentation. Ann Intern Med 1977;86:430–3.[Medline]
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- Morii I, Takashi K, Yagi Y, et al. False aneurysm formation during the chronic phase of myocardial infarction at the margin of a previously-detected true aneurysm. Kokyu To Junkan 1992;40:1013–7.[Medline]
- St. Cyr JA, Fullerton DA. Successful repair of a pseudoaneurysm originating from a true left ventricular aneurysm. Am Heart J 1992;124:1381–2.[Medline]
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[Abstract]
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Abstract
Introduction
