Complete Percutaneous Obliteration of a Post-Infarction Left Ventricular Inferior Wall Pseudoaneurysm

CONTEXT AND OBJECTIVE: There is uncertainty regarding the risk of major complications in patients with left ventricular (LV) infarction complicated by right ventricular (RV) involvement. The aim of this study was to evaluate the impact on hospital mortality and morbidity of right ventricular involvement among patients with acute left ventricular myocardial infarction. DESIGN AND SETTING: Prospective cohort study, at Emergency Care Unit of Hospital Central da Irmandade da Santa Casa de Misericórdia de São Paulo. METHODS: 183 patients with acute myocardial infarction participated in this study: 145 with LV infarction alone and 38 with both LV and RV infarction. The presence of complications and hospital death were compared between groups. RESULTS: 21% of the patients studied had LV + RV infarction. In this group, involvement of the dorsal and/or inferior wall was predominant on electrocardiogram (p < 0.0001). The frequencies of Killip class IV upon admission and 24 hours later were greater in the LV + RV group, along with electrical and hemodynamic complications, among others, and death. The probability of complications among the LV + RV patients was 9.7 times greater (odds ratio, OR = 9.7468; 95% confidence interval, CI: 2.8673 to 33.1325; p < 0.0001) and probability of death was 5.1 times greater (OR = 5.13; 95% CI: 2.2795 to 11.5510; p = 0.0001), in relation to patients with LV infarction alone. CONCLUSIONS: Patients with LV infarction with RV involvement present increased risk of early morbidity and mortality.

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Exertional dyspnea after myocardial infarction: thinking beyond the diagnosis of heart failure

Journal of International Medical Research ◽

10.1177/0300060518785834 ◽

2018 ◽

Vol 46 (11) ◽

pp. 4769-4774

Author(s):

Konstantinos Koutsampasopoulos ◽

Savvas Grigoriadis ◽

Ioannis Vogiatzis

Keyword(s):

Myocardial Infarction ◽

Heart Failure ◽

Ventricular Myocardium ◽

Left Ventricular ◽

Left Ventricular Aneurysm ◽

Left Ventricular Myocardium ◽

Inferior Wall ◽

Delayed Presentation ◽

Exertional Dyspnea ◽

St Elevation

Introduction We herein present an unusual case of a pseudoaneurysm of the left ventricular myocardium, which is a rare and fatal complication of myocardial infarction. Case report A 64-year-old man with a history of bipolar disorder and arterial hypertension was hospitalized for delayed presentation ST-elevation myocardial infarction. He was admitted to our hospital 24 hours after symptom onset. Diagnostic coronary angiography revealed 95% stenosis at the distal third of the right coronary artery, and he underwent a primary percutaneous coronary intervention to the culprit lesion. Despite administration of a diuretic and optimization of other pharmaceutical treatment, his heart failure deteriorated. Electrocardiography showed a sinus rhythm with Q-wave formation in the inferior wall leads (II, III, aVF), T-wave inversion in the same leads, and borderline QT prolongation (QTc of 490 ms). No ST elevation suggestive of left ventricular aneurysm formation was noticed. Forty days later, cardiac ultrasound revealed a dyskinetic cavity (pseudoaneurysm) in continuity with the posterior–inferior wall of the myocardium, resulting in severe mitral valve regurgitation. Unfortunately, the patient died while awaiting surgical treatment. Conclusion Although most patients with left ventricular pseudoaneurysm have a relatively benign outcome, those with symptoms of heart failure must be urgently diagnosed and treated.

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Left Ventricular and adjacent Right ventricular Pseudoaneurysms post acute myocardial infarction communicating via a Ventricular Septal Defect

10.22541/au.160812826.67804259/v1 ◽

2020 ◽

Author(s):

Kevin Kang ◽

John Wilson ◽

Jeffrey Friedel ◽

Angel Flores

Keyword(s):

Myocardial Infarction ◽

Right Ventricular ◽

Color Doppler ◽

Fatal Outcome ◽

Left Ventricular ◽

Inferior Wall ◽

Papillary Muscle Rupture ◽

Mechanical Complications ◽

Muscle Rupture ◽

Echocardiographic Images

The rare but deadly post myocardial infarction (MI) mechanical complications are categorized as ventricular free wall rupture, ventricular septal rupture (VSD) and papillary muscle rupture in decreasing order of incidence. The incidence of the mechanical complications has been mitigated by early revascularization in recent years but mortality remains high. The cardiac rupture if contained by clot, scar and pericardium leads to a LV pseudoaneurysm that delays or diminishes the fatal outcome. Mechanical complications and pseudoaneurysm are recognized by echocardiography. We report a previously unreported occurrence of a pseudoaneurysm involving the adjacent walls of both the ventricles, LV basal and inferoseptal walls and the adjacent right ventricular inferior wall (RV). The LV and RV communicated via a hole in the pseudoaneurysmal wall. The echocardiographic images initially showed the LV pseudoaneurysm bulging into the RV rather than into the pericardium. The color Doppler showed shunting through the LV pseudoaneurysm into the RV creating an unusual VSD. The CT angiograms corroborated the echo findings. The LV pseudoaneurysm had a tear in it and this led to bleeding not into pericardium but into the adjacent RV pseudoaneurysm, hence creating a very unusual VSD. Subsequently, our patient went for surgical repair of pseudoaneurysm and the surgical findings confirmed the imaging findings that there was a massive LV pseudoaneurysm from the inferior and inferoseptal walls, the adjacent RV wall was involved with the pseudoaneurysm and a communication between LV pseudoaneuysm sac and the RV was seen. Such pathology has not been described in the past.

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External Reshaping of the Left Ventricle in Off-Pump Surgery

Innovations Technology and Techniques in Cardiothoracic and Vascular Surgery ◽

10.1097/01.imi.0000220943.58491.df ◽

2006 ◽

Vol 1 (4) ◽

pp. 155-159

Author(s):

Sotirios N. Prapas ◽

Demetrios A. Protogeros ◽

Vassilios N. Kotsis ◽

Ioannis A. Panagiotopoulos ◽

Ioannis P. Raptis ◽

...

Keyword(s):

Coronary Artery ◽

Ejection Fraction ◽

Heart Surgery ◽

Bypass Graft ◽

Lateral Wall ◽

Left Ventricular ◽

Inferior Wall ◽

Off Pump ◽

Anterolateral Wall

Background Dyskinetic areas of the lateral and inferior left ventricular (LV) wall are frequently encountered in patients with coronary artery disease. In clinical practice, all of the techniques described for the restoration of shape and function of the LV require cardiopulmonary bypass. A new technique of LV external reshaping that aims to obtain a near-normal ventricular conical shape is described. This technique is performed during an off-pump coronary artery bypass graft (CABG) operation. It is used mainly on the inferior and lateral walls of the ventricle, but also on the anterolateral wall when warranted. This technique can be considered an alternative to classic aneurysmectomy in high-risk cases. Methods All patients underwent total arterial revascularization without aortic manipulation. Intraoperative transesophageal echocardiography was used in all cases to define the dilated akinetic/dyskinetic area. This area was effectively plicated using interrupted mattress sutures reinforced with Teflon felt or pericardial strips. This technique allows near normalization of the geometry of the ventricle and LV end-diastolic volume reduction. In cases of preexisting mitral regurgitation (MR), a reduction of the MR was observed after lateral wall restoration. From September 2002 to April 2005, the external reshaping technique was applied on 56 cases among 949 off-pump CABG cases (5.9%). A detailed transthoracic echocardiogram was obtained preoperatively. The mean ejection fraction of all enrolled patients was 31.2 ± 7%. The location of the plication was: lateral wall in 22, inferior wall in 16, and anterolateral wall in 18. The average number of coronary anastomoses was 2.6. Twelve patients were found to have 2–3 + MR. All patients were followed up during a period of 35 months. Results One patient died due to severe right ventricular dysfunction. Seven patients developed atrial fibrillation, and one had ventricular tachycardia. During the follow-up period, we observed a reduction of left ventricular end-diastolic diameter and a parallel augmentation of ejection fraction (mean 42.2 ± 4%). The ventricular cavity's architecture was normalized. Among the 12 patients with MR, an improvement of regurgitation was noted in 10 (from 2–3+ to 1–2+). One patient died during the follow-up period, and 1 patient required reoperation due to persistent severe MR. Conclusions The external reshaping of the LV during beating heart surgery is technically feasible, has promising results, and can be performed without major complications.

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2326 Prognostic value of left ventricular mitral annular longitudinal displacement measured by tissue Doppler imaging in patients with acute coronary syndrome

Journal of Clinical and Translational Science ◽

10.1017/cts.2018.178 ◽

2018 ◽

Vol 2 (S1) ◽

pp. 46-46

Author(s):

Mats Lassen ◽

Kristoffer G. Skaarup ◽

Allan Z. Iversen ◽

Peter G. Jørgensen ◽

Flemming J. Olsen ◽

...

Keyword(s):

Prognostic Value ◽

Primary Source ◽

Tissue Doppler ◽

Left Ventricular ◽

Doppler Imaging ◽

Inferior Wall ◽

Longitudinal Displacement ◽

Prognostic Information ◽

Coronary Syndrome ◽

Multivariate Adjustment

OBJECTIVES/SPECIFIC AIMS: To investigate the prognostic value of left ventricular mitral annular longitudinal displacement (LD) measured with color tissue Doppler imaging (TDI) in a large population suffering from acute coronary syndrome (ACS). METHODS/STUDY POPULATION: In total, 501 ACS patients underwent an echocardiography within 9 days after a percutaneous coronary intervention. Regional LD was obtained from the 6 mitral annular regions with TDI and GLD was calculated as an average. RESULTS/ANTICIPATED RESULTS: During a median follow-up time of 4.4 years 46 ACS patients suffered CVD. Mean value of GLD in the population was 8.11mm (±2.4). GLD and LD obtained from the inferior wall remained significant independent predictors after multivariate adjustment for clinical parameters, GLD (HR: 1.43, 95% CI: 1.12–1.82, p=0.014, per 1mm decrease), inferior LD (HR: 1.38, 95% CI: 1.14–1.66, p=0.001). Furthermore, inferior wall LD was the primary source of prognostic information in GLD since only inferior LD remained significant when both measures were included in the same model: GLD (HR: 0.95, 95% CI: 0.64–1.40, p=0.781); inferior LD (HR: 1.60, 95% CI: 1.15–2.22, p=0.005). Of all walls, only inferior wall LD remained as an independent predictor after multivariate adjustment. DISCUSSION/SIGNIFICANCE OF IMPACT: GLD provides independent prognostic information in ACS patients over and beyond all conventional echocardiographic measures. Regional inferior LD was the primary source of prognostic information gained from GLD. GLD proved to be a better predictor of cardiovascular events than conventional echocardiographic measures. This could lead to better risk stratification in the clinical setting and open up for earlier intervention in high-risk individuals.

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P260 Left ventricular pseudoaneurysm manifesting as syncope

European Heart Journal - Cardiovascular Imaging ◽

10.1093/ehjci/jez319.121 ◽

2020 ◽

Vol 21 (Supplement_1) ◽

Author(s):

J A Da Conceicao Pedro Pais ◽

B Picarra ◽

K Congo ◽

M Carrington ◽

A R Santos ◽

...

Keyword(s):

Cardiac Surgery ◽

Coronary Artery ◽

Pericardial Effusion ◽

Coronary Disease ◽

Transthoracic Echocardiography ◽

Lateral Wall ◽

Left Ventricular ◽

Inferior Wall ◽

Cardiac Revascularization ◽

Revascularization Surgery

Abstract Introduction Left ventricular (LV) pseudoaneurysms form when cardiac rupture is contained by adherent pericardium or scar tissue. LV pseudoaneurysm is one of the mechanical complications of myocardial infarctions (MI), particularly inferior wall MI. Although LV pseudoaneurysms are not common, the diagnosis is difficult and they are prone to rupture. Transthoracic echocardiography is commonly used in clinical practice and is usually sufficient to make the diagnosis of LV pseudoaneurysm. Regardless of treatment, patients with LV pseudoaneurysms had a high mortality rate, especially those who did not undergo surgery. Description of the clinical case 74 years-old woman, with previous history of hypertension, dyslipidaemia and type 2 diabetes and stable coronary disease. In June 2018 the patient underwent coronary angiography that revealed left main and 3 vessels coronary disease, Cardiac revascularization surgery was proposed that the patient refused. The patient was stable during 6 months. Four days before presenting to emergency department the patient mentioned intermittent pre-cordial pain associated with exertion. At admission day she felt intense pre-cordial pain, accompanied by sudoresis and nausea, relieving with sublingual nitrate. The patient was hemodynamically stable at admission. Electrocardiogram showed sinus rhythm 65 bpm with 2mm ST-elevation of inferior leads. Troponin I was positive 30 ng/dL. Echocardiogram revealed marked hypokinesia of inferior and lateral wall with moderate depression of global systolic function ans presence of slight circumferential pericardial effusion (6mm in diastole on lateral wall) Emergent coronariography was performed and revealed progression of coronary disease of the right coronary artery with sub-occlusion of the mid segment. Cardiac revascularization surgery was proposed and the patient accepted this time. Echocardiogram was repeated during hospitalization revealed a stable pericardial effusion with reduced dimension comparing to admission. After 3 weeks, while waiting surgery in the ward, the patient was a syncope that resulted in fracture of the distal peroneum. Ecocardiogram was performed and revealed a LV posterior wall pseudoaneurysm through a narrow neck in parasternal long axis view and the presence of large pericardial effusion (Fig 1). The patient was submitted to definitive reparative cardiac surgery with pericardium patch and coronary artery bypass graft from left internal mammary to anterior descending coronary artery. The patient recovered well from the cardiac surgery and at 2 months follow up is alive and without signs of heart failure. This case illustrates the complexity in the management of patients with LV pseudoaneurysm. These patients require substantial critical care, imaging and surgical expertise. A high clinical index of suspicion is needed to avoid missing the diagnosis LV pseudoaneurysm and transthoracic echocardiography is essential to establish the diagnosis. Abstract P260 Figure. Fig 1 - LV pseudoaneurysm

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Conservative Management of Subacute Contained Left Ventricular Rupture after Acute Myocardial Infarction

Indian Journal of Cardiovascular Disease in Women WINCARS ◽

10.1055/s-0038-1669784 ◽

2018 ◽

Vol 03 (01) ◽

pp. 034-038

Author(s):

Bharat Goud C ◽

Johann Christopher

Keyword(s):

Myocardial Infarction ◽

Acute Myocardial Infarction ◽

Color Doppler ◽

Regional Wall Motion ◽

Left Ventricular ◽

Mechanical Complication ◽

Inferior Wall ◽

Early Reperfusion ◽

St Segment Elevation ◽

Myocardial Wall

AbstractLeft ventricular free wall rupture (LVFWR) is a near-fatal mechanical complication of acute myocardial infarction in which an early diagnosis and emergency surgery should be of utmost priority for successful treatment. LVFWR is generally perceived to be universally fatal. Majority of LVFWR patients developing cardiac tamponade die rapidly, while in minority of cases the development of tamponade may be sufficiently slow to allow for diagnosis and successful intervention. In this article, the authors report a case of a 63-year-old male patient diagnosed with an inferoposterior wall myocardial infarction treated with early reperfusion thrombolytic therapy presenting 3 days later with diagnosis of subacute LVFWR. Patient had a history of relapse of chest pain which was severe and prolonged with 2 to 3 mm saddle-shaped ST-segment elevation in lateral leads, detected on a routine electrocardiogram, which led to an urgent bedside transthoracic echocardiogram (TTE). TTE showed regional wall motion abnormality in form of akinetic basal inferior-wall, a small echodense pericardial effusion, and a canalicular tract from endocardium to pericardium, through which color-Doppler examination suggested blood crossing the myocardial wall. A cardiac magnetic resonance imaging further reinforced the possibility of contained LVFWR.

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P1481 Embolic infarct in a known coronary artery disease patient

European Heart Journal - Cardiovascular Imaging ◽

10.1093/ehjci/jez319.906 ◽

2020 ◽

Vol 21 (Supplement_1) ◽

Author(s):

A H Ali ◽

U Alnuaimi ◽

S I Lacau ◽

C Badiu ◽

A C Popescu

Keyword(s):

Myocardial Infarction ◽

Mitral Regurgitation ◽

Transthoracic Echocardiography ◽

Disease Patient ◽

Mitral Annulus ◽

Left Ventricular ◽

Inferior Wall ◽

Mitral Leaflet ◽

St Segment ◽

Posterior Mitral Leaflet

Abstract A 60 y/o diabetic and hypertensive lady with previous anterior infarction treated by primary PCI with stenting of the proximal LAD (2011) and CABG for stent thrombosis, presented for chest pain. Admission ECG showed ST segment elevation in II, III aVF, ST segment depression in V1-V2 (A). Urgent coronary angiography was performed. It showed non-significant lesions on RCA and LCX, occlusion of the proximal LAD stent, patent LIMA to LAD and first diagonal with non-significant stenosis of the distal anastomosis (B). Transthoracic echocardiography (C) showed calcific mass involving the mitral annulus and posterior mitral leaflet, moderate mitral regurgitation, hipokinesia of the basal segment of the inferior wall with preserved LV ejection fraction. Transesophageal echocardiography (D) confirmed the calcified mass involving the mitral annulus and the posterior mitral leaflet. There was no significant mitral stenosis, and mitral regurgitation was moderate. Thoracic CT showed massive mitral calcification and a possible thrombus attached to it. (E) Myocardial infarction was confirmed by troponin rise and fall. The patient was discharged on dual antiplatelet therapy, ACE-I, betablocker and statin. At one month follow-up transthoracic echocardiography the central area of the mitral mass became hypoechogenic, and a bilobated hypermobile structure was seen attached to the ventricular side of the mass (F). Blood cultures were negative and there was no inflammatory syndrome. Cardiac magnetic resonance (H) confirmed myocardial infarction and showed massive calcification of the posterior mitral annulus. TEE performed after another month showed a very long hypermobile structure attached to the mitral annulus calcification, which was entering the left ventricular outflow tract reaching the plane of the aortic valve (G). The patient underwent surgical mitral valve replacement and redo CABG and the mass was excised. The pathologic aspect of the excised material was cazeous and friable (I). The initial presentation was presumably an embolic infarct with cazeous material. Abstract P1481 Figure.

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