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Clinical Images
Left Ventricular Pseudoaneurysm by Cardiac CT Angiography
July 2008
Case Presentation. Although left ventricular (LV) pseudoaneurysm is seen infrequently, it should be recognized and distinguished from the common type of left ventricular aneurysm. The diagnosis can be difficult and the lesions are prone to rupture, thus the condition is associated with a high rate of morbidity and mortality. LV pseudoaneurysms are the result of a contained rupture of the free wall of the myocardium, with the containment being provided by adherent pericardium or scar tissue. Among patients dying of infarction, 17% have been found to have ruptured the heart through the infarcted area.1 Rupture of the free wall is four to five times more common than septal rupture and is usually immediately fatal.1 This is one of the causes responsible for pulseless electrical activity resulting in collapse a few days after infarction, with a peak incidence at 3–5 days.1 Most cases are related to myocardial infarction (MI) (particularly inferior wall MI) and cardiac surgery.2 The other causes are post-surgical rupture at a ventriculotomy site or along a valve annulus after valve replacement. Also implicated, though less commonly, are endocarditis and chest trauma.2 Congestive heart failure, chest pain and dyspnea are the most frequently reported symptoms, but more than 10% of patients may be asymptomatic. Before echocardiography, most cases were discovered at autopsy. Left ventricular angiography has been the most definitive test and can be useful in planning surgery since concomitant coronary angiography can be performed. The treatment is immediate surgical repair, and the need for an early accurate diagnosis cannot be overemphasized. Cardiac computed tomographic angiography (CTA) is an excellent imaging modality for this purpose, as it also allows simultaneous analysis of the coronary tree and other cardiac structures. We present images of a LV pseudoaneurysm in a patient with a past history of anterior MI who underwent coronary bypass grafting 8 years prior. The patient is now undergoing CTA for evaluation of his bypass vessels due to progressive shortness of breath. The patient underwent cardiac catheterization approximately 2 years earlier, which did not include a left ventriculogram. The patient also underwent a cardiac echocardiogram that failed to demonstrate the LV pseudoaneurysm (apex was not well visualized). Thus, this was an “incidentaloma” found only on CTA, and not thought to be causative of his symptoms.
References
- Treasure T. False aneurysm of the left ventricle. Heart 1998;80:7–8.
- Frances C, Romero A, Grady D. Left ventricular pseudoaneurysm. J Am Coll Cardiol 1998;32:557–561.
- Roelandt JR, Sutherland GR, Yoshida K, Yoshikawa J. Improved diagnosis and characterization of left ventricular pseudoaneurysm by Doppler color flow imaging. J Am Coll Cardiol 1988;12:807–811.
- Rumberger JA, Johnston DL. X-ray computed tomography and magnetic resonance imaging of the cardiovascular system. Curr Opin Cardiol 1993;8:1000–1013.
