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False aneurysm of the left ventricle. Diagnosis by magnetic resonance imaging
International Journal of Cardiology 98 (2005) 509 – 510 www.elsevier.com/locate/ijcard
Letter to the Editor
False aneurysm of the left ventricle. Diagnosis by magnetic resonance imaging Giancarlo Casolo a,*, Luigi Rega b, Pierluigi Stefano c, Gianfranco Gensini a a
Clinica Medica e Cardiologia, Azienda Universitaria Ospedalera di Careggi, Viale Morgagni 85, 50123 Florence, Italy b Department of Radiology, Azienda Universitaria Ospedalera di Careggi, Viale Morgagni 85, 50123 Florence, Italy c Department of Cardiac Surgery, Azienda Universitaria Ospedalera di Careggi, Viale Morgagni 85, 50123 Florence, Italy Received 14 July 2003; received in revised form 21 November 2003; accepted 23 November 2003 Available online 23 April 2004
1. Introduction When the heart ruptures inside the pericardium usually cardiac tamponade ensues and without specific measures the patient usually dies [1]. However, survival is possible when recognition of this condition is prompt and the rupture is selflimited [1,2]. The most common cause for left ventricular rupture is a transmural myocardial infarction leading to the disruption of the wall. The pathogenesis of postinfarction wall rupture is complex and involves several factors including wall strain, apoptosis, damaged interstitium, and both inflammatory and healing reaction [3]. Less frequently the site of the ruptured wall is contained by the pericardium or scar tissue and a false aneurysm develops [1,4]. False aneurysms usually represents a complication of myocardial infarction, cardiac surgery, trauma, and infection. As false aneurysms are considered as having a strong propensity for rupture, a prompt diagnosis followed by surgical correction is recommended. Differentiation of true from false left ventricular aneurysms is not easy although several imaging techniques can provide the diagnosis [5,6]. Due to its superior image quality and non-invasive nature a very promising technique in this field is Cardiovascular Magnetic Resonance (CMR) [7]. Recent advances in CMR hardware have permitted the introduction of improved cine sequences. We report a case of false left ventricular aneurysm detected by CMR and the use of a steady-state free precession sequence.
2. Case report A 55-year-old man was referred to our Hospital because of the development of an unusual regional left ventricular * Corresponding author. E-mail address: [email protected] (G. Casolo). 0167-5273/$ - see front matter D 2004 Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.ijcard.2003.11.009
dilatation few days after an acute inferior myocardial infarction treated by systemic thrombolysis. Transthoracic and transesophageal echocardiography showed inferior wall dyskinesia and a large mass related to the left ventricular wall which suggested left ventricular aneurysm with thrombotic deposition. Left ventricular angiography confirmed the presence of a large infero-lateral wall akinesia. Both these
Fig. 1. Breath-Hold Balanced Fast Field Echo Cine—CMR obtained in the four chamber view (upper images) and in the short axis view (lower images). Diastolic images are on the left and systolic images are on the right. A thinned, akinetic region can be seen in the lateral wall of the patient (arrows). The inferior wall of the left ventricle shows dyskinesia while there is an evident increase in thickness of the wall which shows nonhomogeneous signal suggesting the presence of a thrombus. Note also the presence of a normal thickening of the anterior and septal wall and the presence of a small pericardial effusion.
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G. Casolo et al. / International Journal of Cardiology 98 (2005) 509–510
3. Discussion
Fig. 2. Breath-Hold Balanced Fast Field Echo Cine—CMR obtained in the two-chamber sagittal view (upper images) and in the short axis view (lower images). Diastolic images are on the left and systolic images are on the right. The black arrows highlight an inferior wall aneurysm of the left ventricle while the white arrows at this level indicate the outer border of the false aneurysm. These two layers are well distinct and can be seen also in the lower images (short axis). In these latter images, the arrows indicate the presence of a discontinuation of the free wall of the left ventricle indicating the presence of a small rupture. Note the inferior wall dyskinesia at this level.
techniques did not allow to distinguish between the presence of a true from a false aneurysm. CMR was performed with a 1.5 Tesla Scanner (Philips, Intera) implemented with a steady state free precession sequence (Balanced Fast Field Echo) allowing to obtain Cine series during breath-hold. CMR showed a thinned lateral wall of the left ventricle (Fig. 1) with a large thrombus outside the infero-lateral wall of the left ventricle. The inferior wall of the left ventricle appeared thin and dyskinetic but the site of the rupture was located in the lateral wall just below the mitral valve (Fig. 2). The patient underwent surgical repair and a left ventricular false aneurysm was confirmed at operation.
Differentiating a true from false aneurysm can modify the clinical approach to a patient after myocardial infarction, the latter being a condition at high risk of complications and death. The demonstration of a narrow orifice leading to a large aneurysm is considered the most important diagnostic feature. No diagnostic technique can allow the diagnosis in the totality of patients because of the difficulty of showing this orifice [4,6]. This case shows the clinical value of CMR for both the detection of false aneurysm and its differentiation from a true left ventricular aneurysm. There was no large and evident orifice between the left chamber and the false aneurysm. Indeed, the difficulties in the diagnosis of the other diagnostic means were clear after CMR. The lateral wall was very thinned and the site of the rupture was very small, as confirmed at surgery. By using CMR and an improved Cine-MR technique, we were able to detect a previously suspected false aneurysm of the left ventricle. CMR implemented with the most recent cardiac applications may thus represent the best technique for diagnosing left ventricular false aneurysm.
References [1] Coleman JE, Mansfield RJR, Simpson IA. Myocardial infarction and sub-acute ventricular rupture: successful outcome in two cases. Int J Cardiol 2000;73:285 – 7. [2] Figueras J, Cortadellas J, Domingo E, Soler-Soler J. Survival following self-limited left ventricular free wall rupture during myocardial infarction. Management differences between patients with or without pseudoaneurysm formation. Int J Cardiol 2001;79:103 – 11. [3] Beranek JT. Pathogenesis of postinfarction free wall rupture. Int J Cardiol 2002;84:91 – 2. [4] Frances C, Romero A, Grady D. Left ventricular pseudoaneurysm. J Am Coll Cardiol 1998;32:557 – 61. [5] Higgins CB, Lipton MJ, Johnson AD, Peterson KL, Vieweg WV. False aneurysms of the left ventricle. Identification of distinctive clinical, radiographic, and angiographic features. Radiology 1978;127:21 – 7. [6] Brown SL, Gropler RJ, Harris KM. Distinguishing left ventricular aneurysm from pseudoaneurysm. A review of the literature. Chest 1997;111:1403 – 9. [7] Pennell D. Cardiovascular magnetic resonance. Heart 2001;85:581 – 9.
Letter to the Editor
False aneurysm of the left ventricle. Diagnosis by magnetic resonance imaging Giancarlo Casolo a,*, Luigi Rega b, Pierluigi Stefano c, Gianfranco Gensini a a
Clinica Medica e Cardiologia, Azienda Universitaria Ospedalera di Careggi, Viale Morgagni 85, 50123 Florence, Italy b Department of Radiology, Azienda Universitaria Ospedalera di Careggi, Viale Morgagni 85, 50123 Florence, Italy c Department of Cardiac Surgery, Azienda Universitaria Ospedalera di Careggi, Viale Morgagni 85, 50123 Florence, Italy Received 14 July 2003; received in revised form 21 November 2003; accepted 23 November 2003 Available online 23 April 2004
1. Introduction When the heart ruptures inside the pericardium usually cardiac tamponade ensues and without specific measures the patient usually dies [1]. However, survival is possible when recognition of this condition is prompt and the rupture is selflimited [1,2]. The most common cause for left ventricular rupture is a transmural myocardial infarction leading to the disruption of the wall. The pathogenesis of postinfarction wall rupture is complex and involves several factors including wall strain, apoptosis, damaged interstitium, and both inflammatory and healing reaction [3]. Less frequently the site of the ruptured wall is contained by the pericardium or scar tissue and a false aneurysm develops [1,4]. False aneurysms usually represents a complication of myocardial infarction, cardiac surgery, trauma, and infection. As false aneurysms are considered as having a strong propensity for rupture, a prompt diagnosis followed by surgical correction is recommended. Differentiation of true from false left ventricular aneurysms is not easy although several imaging techniques can provide the diagnosis [5,6]. Due to its superior image quality and non-invasive nature a very promising technique in this field is Cardiovascular Magnetic Resonance (CMR) [7]. Recent advances in CMR hardware have permitted the introduction of improved cine sequences. We report a case of false left ventricular aneurysm detected by CMR and the use of a steady-state free precession sequence.
2. Case report A 55-year-old man was referred to our Hospital because of the development of an unusual regional left ventricular * Corresponding author. E-mail address: [email protected] (G. Casolo). 0167-5273/$ - see front matter D 2004 Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.ijcard.2003.11.009
dilatation few days after an acute inferior myocardial infarction treated by systemic thrombolysis. Transthoracic and transesophageal echocardiography showed inferior wall dyskinesia and a large mass related to the left ventricular wall which suggested left ventricular aneurysm with thrombotic deposition. Left ventricular angiography confirmed the presence of a large infero-lateral wall akinesia. Both these
Fig. 1. Breath-Hold Balanced Fast Field Echo Cine—CMR obtained in the four chamber view (upper images) and in the short axis view (lower images). Diastolic images are on the left and systolic images are on the right. A thinned, akinetic region can be seen in the lateral wall of the patient (arrows). The inferior wall of the left ventricle shows dyskinesia while there is an evident increase in thickness of the wall which shows nonhomogeneous signal suggesting the presence of a thrombus. Note also the presence of a normal thickening of the anterior and septal wall and the presence of a small pericardial effusion.
510
G. Casolo et al. / International Journal of Cardiology 98 (2005) 509–510
3. Discussion
Fig. 2. Breath-Hold Balanced Fast Field Echo Cine—CMR obtained in the two-chamber sagittal view (upper images) and in the short axis view (lower images). Diastolic images are on the left and systolic images are on the right. The black arrows highlight an inferior wall aneurysm of the left ventricle while the white arrows at this level indicate the outer border of the false aneurysm. These two layers are well distinct and can be seen also in the lower images (short axis). In these latter images, the arrows indicate the presence of a discontinuation of the free wall of the left ventricle indicating the presence of a small rupture. Note the inferior wall dyskinesia at this level.
techniques did not allow to distinguish between the presence of a true from a false aneurysm. CMR was performed with a 1.5 Tesla Scanner (Philips, Intera) implemented with a steady state free precession sequence (Balanced Fast Field Echo) allowing to obtain Cine series during breath-hold. CMR showed a thinned lateral wall of the left ventricle (Fig. 1) with a large thrombus outside the infero-lateral wall of the left ventricle. The inferior wall of the left ventricle appeared thin and dyskinetic but the site of the rupture was located in the lateral wall just below the mitral valve (Fig. 2). The patient underwent surgical repair and a left ventricular false aneurysm was confirmed at operation.
Differentiating a true from false aneurysm can modify the clinical approach to a patient after myocardial infarction, the latter being a condition at high risk of complications and death. The demonstration of a narrow orifice leading to a large aneurysm is considered the most important diagnostic feature. No diagnostic technique can allow the diagnosis in the totality of patients because of the difficulty of showing this orifice [4,6]. This case shows the clinical value of CMR for both the detection of false aneurysm and its differentiation from a true left ventricular aneurysm. There was no large and evident orifice between the left chamber and the false aneurysm. Indeed, the difficulties in the diagnosis of the other diagnostic means were clear after CMR. The lateral wall was very thinned and the site of the rupture was very small, as confirmed at surgery. By using CMR and an improved Cine-MR technique, we were able to detect a previously suspected false aneurysm of the left ventricle. CMR implemented with the most recent cardiac applications may thus represent the best technique for diagnosing left ventricular false aneurysm.
References [1] Coleman JE, Mansfield RJR, Simpson IA. Myocardial infarction and sub-acute ventricular rupture: successful outcome in two cases. Int J Cardiol 2000;73:285 – 7. [2] Figueras J, Cortadellas J, Domingo E, Soler-Soler J. Survival following self-limited left ventricular free wall rupture during myocardial infarction. Management differences between patients with or without pseudoaneurysm formation. Int J Cardiol 2001;79:103 – 11. [3] Beranek JT. Pathogenesis of postinfarction free wall rupture. Int J Cardiol 2002;84:91 – 2. [4] Frances C, Romero A, Grady D. Left ventricular pseudoaneurysm. J Am Coll Cardiol 1998;32:557 – 61. [5] Higgins CB, Lipton MJ, Johnson AD, Peterson KL, Vieweg WV. False aneurysms of the left ventricle. Identification of distinctive clinical, radiographic, and angiographic features. Radiology 1978;127:21 – 7. [6] Brown SL, Gropler RJ, Harris KM. Distinguishing left ventricular aneurysm from pseudoaneurysm. A review of the literature. Chest 1997;111:1403 – 9. [7] Pennell D. Cardiovascular magnetic resonance. Heart 2001;85:581 – 9.