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Cardiac vignette: Giant left ventricular aneurysm in the setting of emergent transmural ischaemia
Abstract
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a resting gradient of 40mmHg and 110mmHg with Valsalva manoeuvre. (Image 3) A diagnosis of Takotsubo Cardiomyopathy with concurrent HOCM was made. Patient was commenced on an ACE inhibitor and Beta-blockade therapy. Patient was subsequently discharged, with plan for outpatient endomyocardial biopsy and genetic testing. This case brings forth an interesting phenomenon of dual myocardial pathologies, with potential for a pre-existing LVOT gradient providing substrate for development of the typical TCM contracture design in context of a sympathetic surge. http://dx.doi.org/10.1016/j.hlc.2015.06.509 507 Cardiac vignette: Giant left ventricular aneurysm in the setting of emergent transmural ischaemia A. Bhat ∗ , G. Gan, B. Khoury, F. Fernandez Blacktown Hospital, NSW, Australia A 56-year-old female with late presentation of an inferolateral ST segment myocardial infarction (MI) undergoes coronary angiography revealing complete occlusion of the LCx artery requiring complex percutaneous coronary intervention (PCI) and stenting. This is on a background of medically controlled hypertension and reflux disease. Transthoracic echocardiography (TTE) (Image 1) day 3 post infarct revealed a mildly dilated left ventricle (LV) with normal systolic function. Inhomogeneity was noted across the apicolateral LV wall, suggestive of wall weakness. Patient represented post discharged with progressive dyspnoea and chest pain two weeks following the index admission. Repeat TTE was performed which revealed significant impairment of LV function in addition to a prominent LV aneurysm (Image 2), with the neck of the aneurysm measuring 57mm. Patient underwent CT scanning (Image 3) which confirmed a LV aneurysm involving the lateral and inferior walls of the LV, with some involvement of the anterior wall. The patient was referred for LV aneurysmectomy which was performed at a Cardiothoracic Centre, with the aid of a bovine pericardial patch. Follow-up TTE was evaluated which revealed a small residual apicolateral wall aneurysm, with moderate impairment of LV function. (Image 4)
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LV aneurysm post MI is a well-recognised, albeit rare complication in the era of PCI. This case highlights the importance of surveillance echocardiography post-revascularisation in patients with late presentation MIs. http://dx.doi.org/10.1016/j.hlc.2015.06.510 508 Cardiac vignette: Isolated case of right ventricular non-compaction A. Bhat ∗ , G. Gan, F. Fernandez, A. Denniss Blacktown Hospital, NSW, Australia A 33-year-old female experienced a witnessed cardiac arrest in the emergency department. No significant prior medical history. Initial presenting complaint of progressive dyspnoea with ECG findings of sinus tachycardia. Subsequent development of sinus bradycardia on monitoring followed by cardiac arrest requiring cardiopulmonary resuscitation. Urgent bedside transthoracic echocardiography upon successful resuscitation showed severely dilated and dysfunctional right ventricle (RV). Emergent thrombolysis performed with subsequent CTPA showing evidence of extensive filling defects involving the right pulmonary arterial vasculature consistent with acute pulmonary embolism. Formal transthoracic and transoesophageal echocardiography (Images 1 and 2, respectively) were performed showing significant RV dilatation and prominent trabeculations within the RV apex, in keeping with RV non-compaction (RVNC). Cardiac MRI was subsequently performed (Image 3 and 4), confirming diagnosis of RV non-compaction with RV dilatation as well as prominent left ventricular trabeculations. No significant intra-cardiac luminal thrombus was seen. Patient underwent RV endomyocardial biopsy which revealed mild interstitial fibrosis along with significant fat infiltration (30-40% of the biopsy specimen was infiltrated and replaced by fat). No significant myocyte hypertrophy or myofibre disarray was noted. No significant inflammation, granulomas, iron deposits and amyloid deposits were seen. The clinical case illustrates the difficulty faced in diagnosis of RVNC. Along with RV dilatation (found in pulmonary embolism), histopathological findings point to the diagnosis of RV dysplasia. Imaging findings however raise the likelihood of RVNC. Though well described in literature, the histological features of RVNC is yet to be clearly elucidated and hence radiological and clinical correlation is suggested for accurate diagnosis.
S330
a resting gradient of 40mmHg and 110mmHg with Valsalva manoeuvre. (Image 3) A diagnosis of Takotsubo Cardiomyopathy with concurrent HOCM was made. Patient was commenced on an ACE inhibitor and Beta-blockade therapy. Patient was subsequently discharged, with plan for outpatient endomyocardial biopsy and genetic testing. This case brings forth an interesting phenomenon of dual myocardial pathologies, with potential for a pre-existing LVOT gradient providing substrate for development of the typical TCM contracture design in context of a sympathetic surge. http://dx.doi.org/10.1016/j.hlc.2015.06.509 507 Cardiac vignette: Giant left ventricular aneurysm in the setting of emergent transmural ischaemia A. Bhat ∗ , G. Gan, B. Khoury, F. Fernandez Blacktown Hospital, NSW, Australia A 56-year-old female with late presentation of an inferolateral ST segment myocardial infarction (MI) undergoes coronary angiography revealing complete occlusion of the LCx artery requiring complex percutaneous coronary intervention (PCI) and stenting. This is on a background of medically controlled hypertension and reflux disease. Transthoracic echocardiography (TTE) (Image 1) day 3 post infarct revealed a mildly dilated left ventricle (LV) with normal systolic function. Inhomogeneity was noted across the apicolateral LV wall, suggestive of wall weakness. Patient represented post discharged with progressive dyspnoea and chest pain two weeks following the index admission. Repeat TTE was performed which revealed significant impairment of LV function in addition to a prominent LV aneurysm (Image 2), with the neck of the aneurysm measuring 57mm. Patient underwent CT scanning (Image 3) which confirmed a LV aneurysm involving the lateral and inferior walls of the LV, with some involvement of the anterior wall. The patient was referred for LV aneurysmectomy which was performed at a Cardiothoracic Centre, with the aid of a bovine pericardial patch. Follow-up TTE was evaluated which revealed a small residual apicolateral wall aneurysm, with moderate impairment of LV function. (Image 4)
.. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. ..
LV aneurysm post MI is a well-recognised, albeit rare complication in the era of PCI. This case highlights the importance of surveillance echocardiography post-revascularisation in patients with late presentation MIs. http://dx.doi.org/10.1016/j.hlc.2015.06.510 508 Cardiac vignette: Isolated case of right ventricular non-compaction A. Bhat ∗ , G. Gan, F. Fernandez, A. Denniss Blacktown Hospital, NSW, Australia A 33-year-old female experienced a witnessed cardiac arrest in the emergency department. No significant prior medical history. Initial presenting complaint of progressive dyspnoea with ECG findings of sinus tachycardia. Subsequent development of sinus bradycardia on monitoring followed by cardiac arrest requiring cardiopulmonary resuscitation. Urgent bedside transthoracic echocardiography upon successful resuscitation showed severely dilated and dysfunctional right ventricle (RV). Emergent thrombolysis performed with subsequent CTPA showing evidence of extensive filling defects involving the right pulmonary arterial vasculature consistent with acute pulmonary embolism. Formal transthoracic and transoesophageal echocardiography (Images 1 and 2, respectively) were performed showing significant RV dilatation and prominent trabeculations within the RV apex, in keeping with RV non-compaction (RVNC). Cardiac MRI was subsequently performed (Image 3 and 4), confirming diagnosis of RV non-compaction with RV dilatation as well as prominent left ventricular trabeculations. No significant intra-cardiac luminal thrombus was seen. Patient underwent RV endomyocardial biopsy which revealed mild interstitial fibrosis along with significant fat infiltration (30-40% of the biopsy specimen was infiltrated and replaced by fat). No significant myocyte hypertrophy or myofibre disarray was noted. No significant inflammation, granulomas, iron deposits and amyloid deposits were seen. The clinical case illustrates the difficulty faced in diagnosis of RVNC. Along with RV dilatation (found in pulmonary embolism), histopathological findings point to the diagnosis of RV dysplasia. Imaging findings however raise the likelihood of RVNC. Though well described in literature, the histological features of RVNC is yet to be clearly elucidated and hence radiological and clinical correlation is suggested for accurate diagnosis.