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Magnetic resonance images of left ventricular pseudoaneurysm

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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).

Figure 1

T2 weighted spoiled grass image from a cine loop sequence. A large thin wall, sac-like structure (PSA) is seen below the base of the left ventricle (LV).

Figure 2

In midsystole a communication between the postero-basal area of the left ventricle (LV) and the thin walled, sac-like structure (PSA) is seen (arrowheads). The magnetic resonance image of this thin walled structure appears to be consistent with left ventricular pseudoaneurysm.

Figure 3

By late systole a flow void is seen (arrowheads) representing a jet of blood from the left ventricle into the pseudoaneurysm. Blood could be seen swirling around inside the pseudoaneurysm.

Figure 4

T1 weighted gated image at the same level demonstrated the communication between the left ventricle and the pseudoaneurysm (arrowheads). Signal from inside the pseudoaneurysm indicates swirling of blood around with possible thrombus.

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.