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A 63 year old woman presented in March 1997 with a three month history of shortness of breath while lying flat and in the left lateral position. She had a history of ischaemic heart disease and had coronary artery bypass surgery five years ago. In August 1995 she had an inferior wall myocardial infarction with postinfarction angina, which responded to medical treatment. Echocardiographic window was poor because of obesity; however, there appeared to be a large echo free space postero-inferior to the left ventricle leading to suspicion of left ventricular pseudoaneurysm. Magnetic resonance images of the heart performed in a 0.5 Tesla GE Vectra (IGF Medical, Milwaukee, Wisconsin, USA) magnetic resonance scanner were consistent with this diagnosis (figs1-4).
The clinical presentation did not suggest a diagnosis of left ventricular pseudoaneurysm. Chest radiography showed cardiomegaly with left sided pleural effusion. In view of her previous heart attack and coronary artery bypass operation transoesophageal echocardiography was performed followed by a transthoracic echocardiography. The patient was considerably breathless while manoeuvring the probe. However, from a limited study there was a very strong suspicion of left ventricular pseudoaneurysm. After stabilising the patient we performed cardiac catheterisation and angiography. Left ventriculography showed that contrast filled the pseudoaneurysm, but it was diluted in a huge sac. The patient had open heart surgery, which revealed dense adhesions around the heart. The pseudoaneurysm was very large and adherent to the left ventricle, extending over the right ventricle and right atrium. It was not possible to dissect it off the right atrium. After a long dissection the right atrium was split open exposing the tricuspid valve. The pseudoaneurysm was partially resected from the right ventricle. Its connection with the left ventricular wall was identified and the hole was closed. The pseudoaneurysm sac was wrapped postero-inferiorly around the heart encroaching on the right ventricle and the right atrium. The right atrium was densely adherent to the aneurysm wall posteriorly.
After dissection the right atrium was reconstructed. There were several areas of bleeding from the right atrium, which were secured. As it was dissected out from the ventricular walls there was profuse bleeding from the heart surface. Haemodynamically the patient became very unstable, her condition gradually deteriorated and she died.