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A 72-year-old male with recurrent syncope
  1. Dhanuka Perera1,
  2. Rakesh Uppal2,
  3. John Hogan1
    1. 1Department of Cardiology, Barts Heart Centre, St Bartholomew's Hospital, London, UK
    2. 2Department of Cardiothoracic Surgery, St Bartholomew's Hospital, London, UK
    1. Correspondence to Dr Dhanuka Perera, Department of Cardiology, Barts Heart Centre, St Bartholomew's Hospital, West Smithfield, London EC1A 7BE, UK; dhanuka.perera{at}nhs.net

    Abstract

    Clinical introduction A 72-year-old patient presented with recurrent syncope 1 year after a myocardial infarction. Two recent falls resulted in fractures to the femur. Serial troponins were negative and ECG demonstrated fixed inferior ST-segment elevation and pathological Q waves. A Holter monitor recorded non-sustained ventricular tachycardia. A subsequent echocardiogram was abnormal, and further investigation with a three-dimensional (3D) cardiac CT coronary angiogram was performed (figure 1).

    Question What is the most likely diagnosis?

    1. Cardiac tumour

    2. Hypertrophic obstructive cardiomyopathy

    3. Ventricular aneurysm

    4. Ventricular diverticulum

    Statistics from Altmetric.com

    ANSWER: C

    Ventricular aneurysms after myocardial infarction occur due to weakened myocardium due to transmural tissue loss (incidence of approximately 7.6%)1 (see online supplement 1 and online supplementary video 1). Area of non-viable tissue of the aneurysm contributes to the poor ventricular function and patients are prone to ventricular arrhythmias and thromboembolism formation. Initial echocardiogram demonstrated a severely impaired left ventricle and a large inferior septal aneurysm (measuring 6.3×8.7 cm) with a diastolic volume of 633 mL (four times the upper limit of normal) (see online supplement 2 and online supplementary video 2).

    Figure 1

    Cardiac CT coronary angiogram—three-dimensional reconstruction.

    The large aneurysm which contributed to symptomatic poor ventricular function and the presence of extensive scar tissue predisposed to ventricular tachycardia as demonstrated by the Holter. Presence of intractable arrhythmias and heart failure were indications for surgery. Patient underwent saphenous vein grafting to left anterior descending and circumflex arteries with concurrent aneurysmectomy to remove akinetic scar tissue preserving viable contractile myocardium as well as implanting a cardioverter defibrillator (see online supplement 3). One year post surgery, the patient made a very good recovery and remained symptom free with a significantly improved quality of life.

    3D reconstruction of cardiac CT aided the surgical planning and fully appreciated the extent of aneurysm (see online supplementary video 1). Repeat echocardiography demonstrated that the left ventricular ejection fraction had tripled to 30%–35% postoperatively (see online supplement 4 and online supplementary video 3).

    Cardiac tumours are rare findings (0.002%–0.3% of autopsy studies) and the majority are left atrial rather than ventricle lesions (69% vs 7%). They depict masses adhered to the cardiac wall.2

    Hypertrophic cardiomyopathy is associated with ventricular aneurysms, but these are found in the apex with ventricular wall hypertrophy and mid-ventricular obstruction and not in the inferoseptal wall.

    A ventricular diverticulum is an equally rare differential (0.4%) found incidentally in young patients. It results from a developmental abnormality resulting in an outpouching in the ventricular wall, unlikely to presenting late in life.

    References

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    Footnotes

    • Collaborators Mr Delfin Encarnacion, Echo Technician, Department of Cardiology, St Bartholomew's Hospital, London, UK.

    • Contributors I am a clinical fellow in Cardiology working with JH, RU and DE. We were involved in the care of a patient with a very large ventricular aneurysm. The images are rather spectacular and may be of educational value therefore would like to share it with the medical community.

    • Competing interests None declared.

    • Patient consent Obtained.

    • Provenance and peer review Not commissioned; externally peer reviewed.

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