Left Ventricular Pseudoaneurysm: Patching A Life!

Introduction Left ventricular pseudoaneurysm is a rare complication of myocardial infarction where the myocardial wall ruptures but is contained by pericardium or scar. Free wall rupture can lead to cardiac tamponade and death. However, if contained, pseudoaneurysms can form. The most common symptoms reported are heart failure, chest pain and dyspnea. The vast majority of ECGs are abnormal with nonspecific ST changes being the most common. MI has been reported to be the cause for up to 55% of cases, inferior being twice as common as anterior. When comparing imaging modalities, cardiac MRI has been shown to be most conclusive in finding a definitive diagnosis, however angiography and transthoracic echocardiography are frequently employed for diagnosis. Case A 69-year-old male presented with fever, myalgia, cough, and shortness of breath, and was diagnosed with MRSA bacteremia and discitis. TEE showed no definitive evidence of endocarditis. During hospital course, patient developed inferior STEMI and underwent emergent successful PCI to RCA. After being discharged, he was non-compliant to dual antiplatelet therapy and antibiotics, and developed recurrent chest pain, and dyspnea on exertion. He presented to the hospital few weeks later with acute heart failure symptoms and continued chest pain. ECG showed persistent inferolateral ST elevations (Fig, A). Echo showed newly reduced LVEF of 35-40%, and aneurysmal deformity of the mid-apical inferior wall (Fig, B), and severe aortic regurgitation likely due to endocarditis. CMR provided the exact location and dimensions of the large LV pseudoaneurysm/contained LV wall rupture for pre-surgical planning (Fig, C). A successful aortic valve replacement and patch repair of pseudoaneurysm was performed (Fig, D). Summary This case demonstrates a rare complication of MI, appropriate utilization of imaging modalities, and the vast array of diagnoses that may lead to heart failure symptoms. Due to an inferior location, the liver helped tamponade and contain the pseudoaneurysm. This is a hypothesis of why inferior MI is a more common presentation of pseudoaneurysm than anterior MI. As performed successfully in our case, surgery is the definitive treatment. Untreated pseudoaneurysms have a high risk of rupture, up to 45%. Mortality rates are high with surgical and non-surgical management however surgical mortality has been shown to be lower.