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An asymptomatic 61 year old man with a history of coronary artery disease, including coronary artery bypass surgery, presented for routine examination after a lateral myocardial infarction treated by thrombolysis five months previously. Physical examination was unremarkable. Echocardiography revealed a dyskinetic cavity connected to the posterolateral wall which communicated freely with the left ventricle. Magnetic resonance imaging (below left) confirmed the diagnosis of a false aneurysm (A) of the left ventricle (LV) by demonstrating a large perforation of the free posterolateral wall (arrows). Invasive coronary angiography revealed a patent left internal mammary artery graft to the left anterior descending coronary artery. A venous bypass to the left circumflex coronary artery demonstrated a severe stenosis at the distal anastomosis. Open heart surgery was performed. The aneurysmal sac was excised and the defect (below right, arrows) was closed with a pericardial patch. The postsurgical period was uneventful.
Rupture of the left ventricular free wall is a catastrophic complication of myocardial infarction, occurring in approximately 4% of patients with infarcts and about 23% of those suffering fatal infarcts. It is four to five times more common than septal rupture. Rarely, free wall rupture is contained by overlying, adherent pericardium, producing what has been termed a pseudoaneurysm or false aneurysm of the left ventricle. These pseudoaneurysms are often detected incidentally by echocardiography or other imaging modalities. Because of their propensity to rupture, emergency surgical intervention is recommended. The patient survived because the pericardium adhered to the epicardium as a consequence of bypass surgery six years earlier.