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A 51 year old man was admitted with exertional dyspnoea and a grade 1 to-and-fro heart murmur. He had undergone coronary artery bypass graft surgery for severe three vessel coronary artery disease nine months before. Three weeks before admission, he suffered an acute Q wave lateral myocardial infarction which was treated conservatively. Chest x ray on admission showed a pronouced increase of the cardiac silhouette and signs of pulmonary congestion. Echocardiography was performed and revealed a large echo-free space adjacent to the lateral wall of the left ventricle (below left, asterisk) which extended from the apex to the mitral annulus (LA, left atrium; LV, left ventricle; RA, right atrium; RV, right ventricle). A small myocardial rupture (below centre) was identified in the basal lateral left ventricular wall, and colour Doppler imaging showed bidirectional shunting of blood between the left ventricle and the echo-free space (below right), enabling a diagnosis of left ventricular pseudoaneurysm to be made. Moderate mitral regurgitation was also present.
During subsequent heart surgery, the pseudoaneurysm was incised, its fibrous wall was resected, and the ruptured left ventricular myocardium was sutured. The mitral valve needed to be replaced with a mechanical prosthesis. The vein graft to the left circumflex coronary artery was occluded, but because of the small size and distal occlusion of the native vessel, no redo bypass surgery was performed. The patient's postoperative hospital course was uneventful and he was discharged two weeks later.
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