Report of an unusually large ventricular aneurysm∗

Case Reports ReportfanUuslyLrge Ventricular Aneurysm* MORIS

W . DEXTR,M

.D ., ALFRED H . LAWTON,

M .D .,

and ARTHU

. RAYNOLDS,

M .D .

Bay Pines, Florida

murmurs or signs of failure . examination was negative .

aneurysms are rather frequent complications of myocardial infarction, with an incidence ranging from 10 to 20 per cent in large series .'' 2 Theyarfquntldiscovered during life by means of chest x-rays or fluoroscopy . Theanurysm appears as an abnormal bulge in the cardiac silhouette and often exhibits paradoxic pulsations .' Physical findings may suggest ventricular aneurysm by a weak diffuse apical impulse and muffled heart tones, but these are not as definitive as roentOccasionally such genologic examination . aneurysms may reach immense dimensions, asin caserpotdbyShena dNiven, 4 in which the internal diameter of the sac was 16 cm . At the time of their writing this was the largest reported ventricular aneurysm . In the case report which follows, a ventricular aneurysm even larger (over 18 cm) than that of Shena dNivensdcribe .

V

ENTRICULA

Remainder of physical

Laboratory and X-ray Findings : Red blood count 4,920,000 ; hemoglobin 94%, hematocrit 49 ; WBC 10,000 ;BUN1 .5 ; cholesterol 320 ; urinalysis negative ; sedimentation rate 19 ; Kahn negative . ECG showed recent anterior wall infarction . Hospital Course : Theclinadgoswacute coronary occlusion with myocardial infarction . The patient was placed at bed rest and given anticoagulant treatment, including heparin and dicumarol . He improved clinically and after five months was discharged to the domiciliary unit . At time of discharge, his only complaint was occasional angina. SecondAmis : Approximately one year later the patient was admitted for a second time hecause of chest pain and dyspnca . Physical examination was negative except for wheezing and moist rates in the chest . Blood pressure 104/80 ; heart rate 80, gallop rhythm ; no edema . laboratory and X-ray Data : X-ray revealed an aneurysmal bulge along the upper border of the left ventricle . Otherwise, laboratory findings were within normal limits, Hospital Course: Patient responded well to bed rest, 200 mg sodium diet, digitoxin 0 .2 mg daily, nitroglycerin when needed . He was discharged to the domiciliary unit at the end of one month, ThirdAmson : Thepatinwsdmeforth third time 18 months later complaining of generalized weakness with weight loss, nausea, intermittent pain in his chest and shoulders for several months . He had gradually developed more dyspnca, orthopnea, paroxysmal nocturnal dyspnea, and slight dependent edema . Physical examination showed a chronically ill, thin white male who appeared over 60 years of age rather than his actual age of 43 . He was too weak to sit up during an examination . Height 5 ft 10 in . ; weight 137, temperature 98 .6 ; pulse 100 ; blood pressure 110/100 bilaterally . Therwasligtvnou engorgement.

CASEHITORY

This43-yearoldwhitemalwsfirtadm etoBay Pines VA Center two days following a cramping, anterior chest pain which radiated down both arms .The pain was relieved by an injection of a narcotic . The patient gave a past history of bronchial asthma for which he had been discharged from the Navy, and a recent accident, the exact date of which had not been determined, in which he suffered fracture of some left ribs . Physical Examination : Thepatinws eldvoped and well nourished 43-year-old, grey-haired white male, who appeared much older than his chronologic age . Theblodpresu wa135/90andpulse102 . The artsoundwerofgdquality . Therwno

' From the Veterans Administration Center, Bay Pines, Florida . 372

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Dexter, Lawton, and Raynolds Asthmatic wheezes were heard in both lungs . The heart was enlarged, heart sounds feeble, rhythm regular, occasional extrasystole, no murmurs, A2 greater than P2 ; two plus dependent edema. Laboratory and X-ray Data : Urineshowd4pluabmin, otherwise negative . WBG and differential were within normal limits . Red count 4,470,000 ; hemo. globin 90 per cent ; hematocrit 44 . Chest x-ray again showed an aneursmal bulge along the left upper ventricular wall . Lungs showed signs of pulmonary congestion. ECG showed right bundle branch block with possible anterior wall infarction . Hospital course was characterized by severe generalized weakness and episodes of shock with profuse diaphoresis . During these periods his pulse was imperceptible and blood pressure was unobtainable . Five such episodes occurred during his last hospital period . He often required Demerol ® for his chest pain . During his last three weeks he showed evidence of "right-sided failure," which responded poorly to mercuhydrin and low-sodium diet. Therwasevr pigastrcpin, which was partly controlled by Amphogel and Methadon . At the end of the fifth week he complained of severe left pleuritic pain and on the following day he expectorated some bloody sputum . Pericardial and left pleuritic friction rubs were heard . Because of these evidences of pulmonary infarction, he was placed on anticoagulant

Fig. 1 . aSgitalsectionthroughleftventricleshowinglargeanurysmal sac and mural thrombus . sEPriMRNR,

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therapy with Dicumarol . Nevertheless, his chest pains persisted and he developed a fever which failed to respond to penicillin and streptomycin . His condition deteriorated rapidly despite oxygen and other supportive measures . It should be stressed that even at this stage the most salient symptom complex was that of chronic shock rather than right-sided failure. Edema and hepatomegaly appeared late but were never impressive . Following gradual fall in blood pressure the patient expired 46 days after admission.

Necropsy

Revealed:

(1) Aneurysm of left ventricle . (2) Myocardial infarction, old and recent, right and left, due to coronary thrombosis . (3) Mural thrombosis, left ventricle . (4) Pulmonary infarction, left lung, due to embolism . Theanurysmwa nexc dinglythinsacmesuring over 18 cm in internal diameter (Fig . 1) . It was completely filled with a laminated mural thrombus which, though adherent to the ventricular wall, could be easily separated . Calcification of either the thrombus or the aneurysmal sac was not noted . Ther was no conspicuous pericardial reaction . DISCUON

Ventricular aneurysms may attain enormous



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Ventricular Aneurysm

dimensions, as noted above .Thesarcgn-SUMARY ally passive fibrous sacs with virtually no myocardiuln .Theclinapcturemayvrfom forward failure due to low volume output to congestive failure .Thelctroadigms saidtohwpersntS-Tgmelvations but this is not reliable in most instances .' Many cases° are diagnosed antemortem by physical examination but even more frequently by x-ray or fluoroscopy. X-ray often discloses a characteristic bulge along the left cardiac border where such aneurysms are most common . Posterior or diaphragmatic aneurysms, especially those of small size, may be difficult to demonstrate by ordinary means .8-' Fluoroscopy will often show paradoxic movements of the aneurysm during the ventricular cycle . Recently the importance of antemortem diagnosis has been stressed since some may be amenable to surgical treatment10'1I The modynaicsofventricula nerysm constitute an interesting aspect of this problem . Sincemayneursmaelrg than elft ventricle even during diastole and since the aneurysms are passive sacs, ventricular contraction should do little more than distend the aneurysm during systole and make virtually no blood available for ejection through the aortic valve . Indeed, this may contribute greatly to the picture of low output failure so frequently observed in patients with ventricular aneurysm . It is our belief that the reason why this patient, and similar patients, are able to survive with large ventricular aneurysms is because the sac is obliterated by the thrombus . In other words, in large ventricular aneurysms the mural thrombus is a lifesaving factor .

Thecasof patienwhanexcdinglyare ventricular aneurysm has been described . A review of the literature indicates that this may be one of the largest aneurysms yet reported . REFNCS 1 . WANG, C . H ., BLAND, E . F .,andWHITEP . D, : A note on coronary occlusion and myocardial infarction found postmortem at the Massachusetts General Hospital during the twenty-year period from 1926 to 1945, inclusive . Ann . In!, Med . 29 : 601, 1948 . 2 .SCHLITER,J .,HELRSTIN . K.,andKATZ L . N. : Aneurysm of the heart : A correlative study of one hundred and two proved cases . Medicine 33 : 43, 1954. 3 . BERMAN, B. and MCGHIRE, J . : Cardiac aneurysm. Am . J. Med . 8 : 480, 1950. 4 .SHENA,T . and NIvEN, W . :Unusalyrge cardiac aneurysm . J. Path . & Bart. 28 : 390, 1925 . 5 .DRESL,W . and PFEIFFER, R. : Cardiac aneurysm : Report of 10 cases . Ann . In! . Med. 14 : 100, 1940 . 6,SIGLER . H .andSCHNEIDR,J . J . : Diagnosis of cardiac aneurysm . Ann . In! . Nfed . 8 : 1033, 1935 . 7 . CRAWFORD, J . H . : Aneurysm of the heart . Arch . Int. Med. 71 : 502, 1943 . 8 .SCHWEDL,J . B.,SAMETP ., and MEDNICE, H . : Electrokymographic studies of abnormal left ventricular pulsations . Am . Heart J. 40 : 410, 1950 . 9 . DICK, M . M. : Aneurysms of the posterior ventricular wall.South . M. J . 48 : 465, 1955 . 10. LIROFF, W. and BAILEY, C . P . : Ventriculoplasty ; excision of myocardial aneurysm ; report of a successful case . J.A .M .A . 158 : 915, 1955 . 11 . DECAMP, P.T . : Excision of an aneurysm of the left ventricle . Osrhnel Cline Reports 2 : 38, 1956 .

THEAMRICNJOULFARDIGY