Large hole no low-flow symptoms

    Authors

    Keywords

    pseudoaneurysm, cardiac heart surgery, left ventricular dysfunction, myocardial infarction

    DOI

    https://doi.org/10.15836/ccar2025.163

    Full Text

    **Introduction**: Left ventricular pseudoaneurysm (PSAN) is a rare condition that occurs because of myocardial free wall rupture, mostly located posterolateral. The most prevalent causes of PSAN are acute myocardial infarction (55%), cardiac surgery (33%), trauma (7%) and infection (5%). It can be asymptomatic, but it may also cause symptoms of heart failure, arrhythmias, thromboembolic events, and sudden cardiac death (1). Treatment is surgical. **Case report**: 50-year-old patient experienced a myocardial infarction without ST elevation. Angiography revealed severe stenosis of the mid-LAD (LAD = left anterior descending artery) and subocclusion of the OM2 (second obtuse marginal) branch. The LAD lesion was treated with stent implantation, and the obtuse marginal arteries lesion were addressed with drug-coated balloons. Echocardiography showed a dilated left ventricle, reduced global ejection fraction (LVEF 38%), and hypokinesia of the inferoposterolateral wall. During a regular cardiology follow-up after 3 months, the patient was asymptomatic, normotensive, and had normal heart rate. The laboratory findings showed only slightly elevated NT-proBNP levels at 1214 pg/ml. Echocardiography revealed a large PSAN of the posterolateral wall. The wall defect measured 34x35mm, and the PSAN itself was almost 7 cm in size, with some thrombotic deposits present (**Figure 1A**). Computed tomography confirmed the presence of a large PSAN in basal posterolateral wall (**Figure 1B**). The patient underwent cardiac surgery, which involved the excision of the LV pseudoaneurysm and patch repair of free wall rupture. The operation was uneventful (Dor procedure) (**Figure 2**). Follow-up echocardiography showed echogenic myocardium of the posterolateral wall (patch), no interruption of myocardial continuity, and continued hypokinesia and dyskinesia of the same region (**Figure 3A**). The global LVEF was reduced to 35%. Postoperative CT confirmed no residual wall microdefects (**Figure 3B**). The patient’s postoperative recovery proceeded well, and he was discharged 7 days postoperatively. FIGURE 1. A) preoperative transthoracic echocardiogram: the four chamber view showing pseudoaneurysm (PSAN) of the posterolateral wall; B) preoperative computed tomography: large PSAN in the basal posterolateral wall. FIGURE 2. Intraoperative photographs show the posterolateral left ventricular pseudoaneurysm. FIGURE 3. A) Postoperative transthoracic echocardiogram: the two chamber view showing the basal lateral wall patch; B) postoperative computed tomography: no residual wall microdefects. **Conclusion**: Asymptomatic patients with PSAN are quite rare and echocardiography is key method for early diagnosis. Surgical treatment is recommended for large pseudoaneurysms, symptomatic patients, and for those discovered within 3 months after myocardial infarction. Due to significantly higher perioperative mortality for patients with PSAN occurring within 2 weeks of myocardial infarction, it should consider deferring surgery for patients with stable acute ventricular pseudoaneurysms to reduce the risks associated with early repair (2).

    Literature

    1. Alshammari BS, Reardon MJ, Nabi F. Late Left Ventricular Pseudoaneurysm after Acute Myocardial Infarction. Methodist DeBakey Cardiovasc J. 2017 July-September;13(3):169–71. https://doi.org/10.14797/mdcj-13-3-169
    2. Soon KJ, Kyung HK, Jong HK, Tae YK. Surgical Repair of Postinfarction Left Ventricular Pseudoaneurysm. Tex Heart Inst J. 2024 October 1;51(2):e248405. https://doi.org/10.14503/THIJ-24-8405
    Cardiologia Croatica
    Back to search

    Large hole no low-flow symptoms

    Extended Abstract
    Issue5-6
    Published
    Pages163-164
    PDF via DOIhttps://doi.org/10.15836/ccar2025.163
    pseudoaneurysm
    cardiac heart surgery
    left ventricular dysfunction
    myocardial infarction

    Authors

    Dubravka Šušnjar*ORCIDDubrava University Hospital, Zagreb, Croatia
    Tomislava Bodrožić Džakić PoljakORCIDDubrava University Hospital, Zagreb, Croatia
    Tomo SvagušaORCIDDubrava University Hospital, Zagreb, Croatia
    Davor BarićORCIDDubrava University Hospital, Zagreb, Croatia
    Daniel UnićORCIDDubrava University Hospital, Zagreb, Croatia
    Josip VarvodićORCIDDubrava University Hospital, Zagreb, Croatia
    Marko KušurinORCIDDubrava University Hospital, Zagreb, Croatia
    Savica GjeorgjievskaORCIDDubrava University Hospital, Zagreb, Croatia
    Gloria ŠestanORCIDDubrava University Hospital, Zagreb, Croatia
    Nikola SliškovićORCIDDubrava University Hospital, Zagreb, Croatia
    Šime ManolaORCIDDubrava University Hospital, Zagreb, Croatia
    Igor RudežORCIDDubrava University Hospital, Zagreb, Croatia

    *Correspondence email: dubravka.susnjar@gmail.com

    Full Text

    Introduction: Left ventricular pseudoaneurysm (PSAN) is a rare condition that occurs because of myocardial free wall rupture, mostly located posterolateral. The most prevalent causes of PSAN are acute myocardial infarction (55%), cardiac surgery (33%), trauma (7%) and infection (5%). It can be asymptomatic, but it may also cause symptoms of heart failure, arrhythmias, thromboembolic events, and sudden cardiac death (1). Treatment is surgical.

    Case report: 50-year-old patient experienced a myocardial infarction without ST elevation. Angiography revealed severe stenosis of the mid-LAD (LAD = left anterior descending artery) and subocclusion of the OM2 (second obtuse marginal) branch. The LAD lesion was treated with stent implantation, and the obtuse marginal arteries lesion were addressed with drug-coated balloons. Echocardiography showed a dilated left ventricle, reduced global ejection fraction (LVEF 38%), and hypokinesia of the inferoposterolateral wall. During a regular cardiology follow-up after 3 months, the patient was asymptomatic, normotensive, and had normal heart rate. The laboratory findings showed only slightly elevated NT-proBNP levels at 1214 pg/ml. Echocardiography revealed a large PSAN of the posterolateral wall. The wall defect measured 34x35mm, and the PSAN itself was almost 7 cm in size, with some thrombotic deposits present (Figure 1A). Computed tomography confirmed the presence of a large PSAN in basal posterolateral wall (Figure 1B). The patient underwent cardiac surgery, which involved the excision of the LV pseudoaneurysm and patch repair of free wall rupture. The operation was uneventful (Dor procedure) (Figure 2). Follow-up echocardiography showed echogenic myocardium of the posterolateral wall (patch), no interruption of myocardial continuity, and continued hypokinesia and dyskinesia of the same region (Figure 3A). The global LVEF was reduced to 35%. Postoperative CT confirmed no residual wall microdefects (Figure 3B). The patient’s postoperative recovery proceeded well, and he was discharged 7 days postoperatively.

    FIGURE 1. A) preoperative transthoracic echocardiogram: the four chamber view showing pseudoaneurysm (PSAN) of the posterolateral wall; B) preoperative computed tomography: large PSAN in the basal posterolateral wall.

    FIGURE 2. Intraoperative photographs show the posterolateral left ventricular pseudoaneurysm.

    FIGURE 3. A) Postoperative transthoracic echocardiogram: the two chamber view showing the basal lateral wall patch; B) postoperative computed tomography: no residual wall microdefects.

    Conclusion: Asymptomatic patients with PSAN are quite rare and echocardiography is key method for early diagnosis. Surgical treatment is recommended for large pseudoaneurysms, symptomatic patients, and for those discovered within 3 months after myocardial infarction. Due to significantly higher perioperative mortality for patients with PSAN occurring within 2 weeks of myocardial infarction, it should consider deferring surgery for patients with stable acute ventricular pseudoaneurysms to reduce the risks associated with early repair (2).

    Literature

    1. 1.
      Alshammari BS, Reardon MJ, Nabi F. Late Left Ventricular Pseudoaneurysm after Acute Myocardial Infarction. Methodist DeBakey Cardiovasc J. 2017 July-September;13(3):169–71.DOI
    2. 2.
      Soon KJ, Kyung HK, Jong HK, Tae YK. Surgical Repair of Postinfarction Left Ventricular Pseudoaneurysm. Tex Heart Inst J. 2024 October 1;51(2):e248405.DOI