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Left ventricular pseudoaneurysm: Detection and postoperative follow-up by color Doppler echocardiography
990
Brief Communications
American
October 1990 Heart Journal
Fig. 2. Transesophagealechocardiographicview of the samepatient as in Fig. 1 in sinus rhythm. The “smoke” is now localized to the left atria1 appendage.
4. Beppu S, Nimura Y, Sakakibara H, Nagata S, Park YD, Izumi S. Smoke-like echo in the left atrial cavity in mitral valve disease: its features and significance. J Am Co11 Cardiol 1985;6:744-9. 5. Daniel WG, Nellessen U, Schroder E, Nonnast-Daniel B, Bednarski P, Nikutta P, Lichtlen PR. Left atria1 spontaneous echo contrast in mitral valve disease. An indicator for an increased thromboembolic risk. J Am Co11Cardiol1988;11:120411.
Left ventricular pseudoaneurysm: Detection and postoperative follow-up color Doppler echocardiography
by
Benjamin Rueda, MD, Ioannis P. Panidis, MD, Ray Gonzales, and Michael McDonough, MD. Philadelphia,
Pa.
Ventricular rupture following myocardial infarction results in hemopericardium with cardiac tamponade and is invariably fatal unless surgical intervention is urgently undertaken. Rarely, adherent parietal pericardium confines the myocardial rupture and creates a pseudoaneurysm or falseaneurysm,a large thin-walled sacwith a small narrow-necked orifice communicatingwith the left ventricle. Spontaneousrupture of pseudoaneurysms,however, is a well-recognized complication, sothat early and accurate diagnosisis essentialbecausethis condition is amenableto surgical cure.le3Two-dimensional and Doppler echocarFrom the Division sity Hospital. Reprint University 414122684
of Cardiology,
Department
requests: Ioannis P. Panidis, Hospital, 3401 N. Broad
of Medicine,
MD, Section St., Philadelphia,
Temple
Univer-
of Cardiology, PA 19140.
Temple
diography have been very helpful in the detection of pseudoaneurysms.4-8 We describea patient with a pseudoaneurysmcharacterized by multiple communicationswith the posterior left ventricular wall clearly demonstrated by color-flow Doppler echocardiography and postoperative residual flow disturbance at the site of repair, that eventually resolved 2 months after surgery. A 64-year-old man with coronary artery bypasssurgery 9 years before was admitted with an acute anterior wall myocardial infarction. He had sustained an inferior wall infarction 3 months previously. On admission,there were no clinical signsof heart failure; a grade 2/6 holosystolic murmur was heard at the apex. On the chest roentgenogramlung fieldswerenormal and cardiomegalywaspresent. Electrocardiogram revealed an evolving acute anterior wall myocardial infarction and a previous inferior infarct. Coronary arteriography showednear-total occlusionof the left main coronary artery, patent saphenousvein graft to the diagonal branch, and a 90% distal lesion in the saphenous vein graft to the left anterior descendingartery. The left circumflex artery wastotally occludedafter the first obtuse marginal branch. A radionuclide ventriculogram demonstrated an inferoposterior accessorychambercommunicating with the left ventricle. Two-dimensional echocardiography revealed akinesis of the distal septum and apex, severehypokinesisof the inferior wall, and an apical laminated thrombus. A large inferoposterior saccularchamber wasvisualized, communicatingwith multiple orifices with the left ventricle (Fig. 1, A, top). Bidirectional phasicflow into and out of the pseudoaneurysmwas confirmed by pulsedDoppler echocardiography,and two distinct systolic jets wereclearly visualized by color-flow Doppler mapping (Fig. 1, A, bottom). Mild mitral regurgitation waspresent. At surgery, six communicationsbetween the pseudoaneurysm and the left ventricle werefound and were closedwith pledget-supported horizontal mattress sutures. The pseudoaneurysmitself wasplicated and wasreclosedin an
Volume Number
120 4
Brief Communications
99 1
1. Top panels, Preoperative two-dimensional echocardiogram (A) from an apical long-axis view showinga large inferoposterior false aneurysm (FA) communicating with the left ventricle (LV) through multiple narrow OrifiCeS (arrows). Postoperatively, a persistent but smaller saccular echo-free spaceis demonstrated (B). Bottom panels, Preoperative color-flow Doppler echocardiogram(A) from an apical long-axis view clearly demonstratestwo jets of systolic flow into the pseudoaneurysmthrough two distinct orifices (arrows). Six days postoperatively (B), a residual bidirectional shunt is seenwith flow into the pseudoaneurysmin systole (arrow) and back into the left ventricle in diastole. AO, Aorta; LA, left atrium.
Fig.
attempt to control postoperative oozing from the repairs. The left internal mammary artery was then anastomosed to the vein graft to the left anterior descendingcoronary artery. An echocardiographicstudy 6 days postoperatively demonstrated a persistent but smaller saccular echo-free spacebehind the inferoposterior wall, as well as bidirectional shunt through one site of repair, with flow into the pseudoaneurysmin systoleand back into the left ventricle in diastole (Fig. 1, B). The patient bad an uneventful recovery and wasdischarged10days after surgery. An outpatient echocardiogram2 weekslater continued to demonstrate the residual flow disturbance, but the patient remained asymptomatic. Finally, an echocardiogramdone 2 months after surgery could no longer demonstrate the shunt. A radionuclide ventriculogram confirmed that the residual communciation was no longer present (Fig. 2). M-mode echocardiography has limitations in recognizing anterobasal and apical left ventricular pseudoaneu-
rysms. Two-dimensional echocardiography demonstrates more accurately the location of the saccular chamber and the narrow-necked communication with the left ventricle.5 However, this technique may fail to distinguisha falsefrom a true ventricular aneurysm and also from a large left pleural effusion, a pericardial effusion or cyst, or an aneurysm of the descending thoracic aorta, especially when visualization of the orifice of the accessorychamberis suboptimal. Doppler echocardiography can confirm this diagnosis by demonstrating turbulent shunt flow at the suspected area of myocardial interruption, proving that a communication exists between the two chambers.6* 8 In the present study, two-dimensionalechocardiography clearly showeda large posterior saccularspacecommunicating with the left ventricle through multiple narrowneckedorifices. Color-flow Doppler mapping unequivocally confirmed the presence of bidirectional shunting flow across these orifices.4 The postoperative evaluation re-
992
Brief Communications
American
October 1990 Heart Journal
Fig. 2. Preoperative radionuclide ventriculogram in the lateral projection (A) demonstratesthe characteristic hourglassconfiguration of a large inferoposterior false aneurysm (FA) with narrow communication with the left ventricle (LV). Seven weeksafter surgical repair, the saccularaccessorychamber is no longer visualized (B).
vealed a residual bidirectional flow disturbance acrossone site of the repair, with subsequent resolution over a 2-month period. The clinical importance of such a residual flow abnormality rests on the differentiation between inadequate or incomplete surgical repair and a transient postoperative shunting acrosssuture lines that will eventually obliterate or endothelialize. In that respect,this residual flow abnormality appearsanalogousto flow disturbances described after ventricular septal defect patch repair, where it hasbeen postulated to occur along the suture line and not through the patch material itself.grlo This study illustrates the usefulnessof serial postoperative echocardiographicand color Doppler evaluation in ascertaining the true nature of post-repair residualshunting. We conclude that the diagnosisof a pseudoaneurysmand the detection of shunting flow through its communication with the left ventricle can be significantly facilitated by colorflow Doppler imaging. Early residual shunting after surgical repair may indicate a transient flow disturbance along suture lines, with subsequentobliteration or endothelialization. REFERENCES
I. Roberts cle. Am 2. Gueron aneurysm Thor& 3. Davidson Fishbein
WC, Morrow AG. Pseudoaneurysm of the left ventriJ Cardiol 1967;43:639-44. M. Wanderman KL. Hirsch M, Borman J. Pseudoof the left ventricle after mybcardial infarction. J Cardiovasc Surg 1975;69:736-42. KH. Parisi AF. Harrineton JJ. Bareamian EM. MC. ‘Pseudoaneurysm of-the left ve&icle: an un: usual echocardiographic presentation. Ann Intern Med 1977;86:430-3. 4. Roelandt J, Sutherland GR, Yoshida K, Yoshikawa J. Improved diagnosis and characterization of left ventricular pseudoaneurysm by Doppler color flow imaging. J Am Co11 Cardiol 1988;12:807-11. 5. Catherwood E, Mintz GS, Kotler MN, Parry WR, Segal BL.
Two-dimensional echocardiographic recognition of left ventricular pseudoaneurysm. Circulation 1980;62:294-303. 6. Wang R, DeSantola JR, Reichek N, Edie R. An unusual case of postoperative pseudoaneurysm of the left ventricle: Doppler echocardiographic findings. J Am Co11 Cardiol1986;8:699102. I. Sorensen SG, Crawford MH, Richards KL, Chaudhuri TK, O’Rourke RA. Noninvasive detection of ventricular aneurysm by combined two-dimensional echocardiography and equilibAM HEART J 1982;104z145-52. rium radionuclide angiography. 8. Loperfido F, Pennestri F, Mazzari M, Biasucci LM, Vigna C, Laurenzi F, Manzoli U. Diagnosis of left ventricular pseudoaneurysm by pulsed Doppler echocardiography. AM HEART J
1985;110:1291-3. L, Pieroni D, Roland J, Shemalek J. Recognition 9. Valdez-Cruz of residual post-operative shunts by contrast echocardiographic techniques. Circulation 1977;55:148-52. 10. Stevenson JG. Kawabori I. Stamm SJ. Bailev WW. Hall DG. Mansfield PB: Rittenhousk EA. Pulsed Doppler echocardio: graphic evaluation of ventricular septal defect patches. Circulation 1984;7O(suppl 1):38-46.
Congenital left atrial appendage aneurysm with intact pericardium: Diagnosis by transesophageal echocardiography Keith Allen Comess,MD,a Dennis Peter Labate, RCDS, CRT,a Jerrold A. Winter, MD,a Arthur C. Hill, MD,b and D. Craig Miller, MD.b Stanford, Calif. From the Departments of%ternal Medicine (Cardiology) and hCardiovascular Surgery, Santa Clara Valley Medical Center and Stanford University School of Medicine. Reprint requests:Keith Comess,MD, Cardiology, Room 522, SCVMC, 751 South Bascom Ave., San Jose, CA 95128. 4/4122682
Brief Communications
American
October 1990 Heart Journal
Fig. 2. Transesophagealechocardiographicview of the samepatient as in Fig. 1 in sinus rhythm. The “smoke” is now localized to the left atria1 appendage.
4. Beppu S, Nimura Y, Sakakibara H, Nagata S, Park YD, Izumi S. Smoke-like echo in the left atrial cavity in mitral valve disease: its features and significance. J Am Co11 Cardiol 1985;6:744-9. 5. Daniel WG, Nellessen U, Schroder E, Nonnast-Daniel B, Bednarski P, Nikutta P, Lichtlen PR. Left atria1 spontaneous echo contrast in mitral valve disease. An indicator for an increased thromboembolic risk. J Am Co11Cardiol1988;11:120411.
Left ventricular pseudoaneurysm: Detection and postoperative follow-up color Doppler echocardiography
by
Benjamin Rueda, MD, Ioannis P. Panidis, MD, Ray Gonzales, and Michael McDonough, MD. Philadelphia,
Pa.
Ventricular rupture following myocardial infarction results in hemopericardium with cardiac tamponade and is invariably fatal unless surgical intervention is urgently undertaken. Rarely, adherent parietal pericardium confines the myocardial rupture and creates a pseudoaneurysm or falseaneurysm,a large thin-walled sacwith a small narrow-necked orifice communicatingwith the left ventricle. Spontaneousrupture of pseudoaneurysms,however, is a well-recognized complication, sothat early and accurate diagnosisis essentialbecausethis condition is amenableto surgical cure.le3Two-dimensional and Doppler echocarFrom the Division sity Hospital. Reprint University 414122684
of Cardiology,
Department
requests: Ioannis P. Panidis, Hospital, 3401 N. Broad
of Medicine,
MD, Section St., Philadelphia,
Temple
Univer-
of Cardiology, PA 19140.
Temple
diography have been very helpful in the detection of pseudoaneurysms.4-8 We describea patient with a pseudoaneurysmcharacterized by multiple communicationswith the posterior left ventricular wall clearly demonstrated by color-flow Doppler echocardiography and postoperative residual flow disturbance at the site of repair, that eventually resolved 2 months after surgery. A 64-year-old man with coronary artery bypasssurgery 9 years before was admitted with an acute anterior wall myocardial infarction. He had sustained an inferior wall infarction 3 months previously. On admission,there were no clinical signsof heart failure; a grade 2/6 holosystolic murmur was heard at the apex. On the chest roentgenogramlung fieldswerenormal and cardiomegalywaspresent. Electrocardiogram revealed an evolving acute anterior wall myocardial infarction and a previous inferior infarct. Coronary arteriography showednear-total occlusionof the left main coronary artery, patent saphenousvein graft to the diagonal branch, and a 90% distal lesion in the saphenous vein graft to the left anterior descendingartery. The left circumflex artery wastotally occludedafter the first obtuse marginal branch. A radionuclide ventriculogram demonstrated an inferoposterior accessorychambercommunicating with the left ventricle. Two-dimensional echocardiography revealed akinesis of the distal septum and apex, severehypokinesisof the inferior wall, and an apical laminated thrombus. A large inferoposterior saccularchamber wasvisualized, communicatingwith multiple orifices with the left ventricle (Fig. 1, A, top). Bidirectional phasicflow into and out of the pseudoaneurysmwas confirmed by pulsedDoppler echocardiography,and two distinct systolic jets wereclearly visualized by color-flow Doppler mapping (Fig. 1, A, bottom). Mild mitral regurgitation waspresent. At surgery, six communicationsbetween the pseudoaneurysm and the left ventricle werefound and were closedwith pledget-supported horizontal mattress sutures. The pseudoaneurysmitself wasplicated and wasreclosedin an
Volume Number
120 4
Brief Communications
99 1
1. Top panels, Preoperative two-dimensional echocardiogram (A) from an apical long-axis view showinga large inferoposterior false aneurysm (FA) communicating with the left ventricle (LV) through multiple narrow OrifiCeS (arrows). Postoperatively, a persistent but smaller saccular echo-free spaceis demonstrated (B). Bottom panels, Preoperative color-flow Doppler echocardiogram(A) from an apical long-axis view clearly demonstratestwo jets of systolic flow into the pseudoaneurysmthrough two distinct orifices (arrows). Six days postoperatively (B), a residual bidirectional shunt is seenwith flow into the pseudoaneurysmin systole (arrow) and back into the left ventricle in diastole. AO, Aorta; LA, left atrium.
Fig.
attempt to control postoperative oozing from the repairs. The left internal mammary artery was then anastomosed to the vein graft to the left anterior descendingcoronary artery. An echocardiographicstudy 6 days postoperatively demonstrated a persistent but smaller saccular echo-free spacebehind the inferoposterior wall, as well as bidirectional shunt through one site of repair, with flow into the pseudoaneurysmin systoleand back into the left ventricle in diastole (Fig. 1, B). The patient bad an uneventful recovery and wasdischarged10days after surgery. An outpatient echocardiogram2 weekslater continued to demonstrate the residual flow disturbance, but the patient remained asymptomatic. Finally, an echocardiogramdone 2 months after surgery could no longer demonstrate the shunt. A radionuclide ventriculogram confirmed that the residual communciation was no longer present (Fig. 2). M-mode echocardiography has limitations in recognizing anterobasal and apical left ventricular pseudoaneu-
rysms. Two-dimensional echocardiography demonstrates more accurately the location of the saccular chamber and the narrow-necked communication with the left ventricle.5 However, this technique may fail to distinguisha falsefrom a true ventricular aneurysm and also from a large left pleural effusion, a pericardial effusion or cyst, or an aneurysm of the descending thoracic aorta, especially when visualization of the orifice of the accessorychamberis suboptimal. Doppler echocardiography can confirm this diagnosis by demonstrating turbulent shunt flow at the suspected area of myocardial interruption, proving that a communication exists between the two chambers.6* 8 In the present study, two-dimensionalechocardiography clearly showeda large posterior saccularspacecommunicating with the left ventricle through multiple narrowneckedorifices. Color-flow Doppler mapping unequivocally confirmed the presence of bidirectional shunting flow across these orifices.4 The postoperative evaluation re-
992
Brief Communications
American
October 1990 Heart Journal
Fig. 2. Preoperative radionuclide ventriculogram in the lateral projection (A) demonstratesthe characteristic hourglassconfiguration of a large inferoposterior false aneurysm (FA) with narrow communication with the left ventricle (LV). Seven weeksafter surgical repair, the saccularaccessorychamber is no longer visualized (B).
vealed a residual bidirectional flow disturbance acrossone site of the repair, with subsequent resolution over a 2-month period. The clinical importance of such a residual flow abnormality rests on the differentiation between inadequate or incomplete surgical repair and a transient postoperative shunting acrosssuture lines that will eventually obliterate or endothelialize. In that respect,this residual flow abnormality appearsanalogousto flow disturbances described after ventricular septal defect patch repair, where it hasbeen postulated to occur along the suture line and not through the patch material itself.grlo This study illustrates the usefulnessof serial postoperative echocardiographicand color Doppler evaluation in ascertaining the true nature of post-repair residualshunting. We conclude that the diagnosisof a pseudoaneurysmand the detection of shunting flow through its communication with the left ventricle can be significantly facilitated by colorflow Doppler imaging. Early residual shunting after surgical repair may indicate a transient flow disturbance along suture lines, with subsequentobliteration or endothelialization. REFERENCES
I. Roberts cle. Am 2. Gueron aneurysm Thor& 3. Davidson Fishbein
WC, Morrow AG. Pseudoaneurysm of the left ventriJ Cardiol 1967;43:639-44. M. Wanderman KL. Hirsch M, Borman J. Pseudoof the left ventricle after mybcardial infarction. J Cardiovasc Surg 1975;69:736-42. KH. Parisi AF. Harrineton JJ. Bareamian EM. MC. ‘Pseudoaneurysm of-the left ve&icle: an un: usual echocardiographic presentation. Ann Intern Med 1977;86:430-3. 4. Roelandt J, Sutherland GR, Yoshida K, Yoshikawa J. Improved diagnosis and characterization of left ventricular pseudoaneurysm by Doppler color flow imaging. J Am Co11 Cardiol 1988;12:807-11. 5. Catherwood E, Mintz GS, Kotler MN, Parry WR, Segal BL.
Two-dimensional echocardiographic recognition of left ventricular pseudoaneurysm. Circulation 1980;62:294-303. 6. Wang R, DeSantola JR, Reichek N, Edie R. An unusual case of postoperative pseudoaneurysm of the left ventricle: Doppler echocardiographic findings. J Am Co11 Cardiol1986;8:699102. I. Sorensen SG, Crawford MH, Richards KL, Chaudhuri TK, O’Rourke RA. Noninvasive detection of ventricular aneurysm by combined two-dimensional echocardiography and equilibAM HEART J 1982;104z145-52. rium radionuclide angiography. 8. Loperfido F, Pennestri F, Mazzari M, Biasucci LM, Vigna C, Laurenzi F, Manzoli U. Diagnosis of left ventricular pseudoaneurysm by pulsed Doppler echocardiography. AM HEART J
1985;110:1291-3. L, Pieroni D, Roland J, Shemalek J. Recognition 9. Valdez-Cruz of residual post-operative shunts by contrast echocardiographic techniques. Circulation 1977;55:148-52. 10. Stevenson JG. Kawabori I. Stamm SJ. Bailev WW. Hall DG. Mansfield PB: Rittenhousk EA. Pulsed Doppler echocardio: graphic evaluation of ventricular septal defect patches. Circulation 1984;7O(suppl 1):38-46.
Congenital left atrial appendage aneurysm with intact pericardium: Diagnosis by transesophageal echocardiography Keith Allen Comess,MD,a Dennis Peter Labate, RCDS, CRT,a Jerrold A. Winter, MD,a Arthur C. Hill, MD,b and D. Craig Miller, MD.b Stanford, Calif. From the Departments of%ternal Medicine (Cardiology) and hCardiovascular Surgery, Santa Clara Valley Medical Center and Stanford University School of Medicine. Reprint requests:Keith Comess,MD, Cardiology, Room 522, SCVMC, 751 South Bascom Ave., San Jose, CA 95128. 4/4122682