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A 76 year old man with no prior cardiac history was admitted after three episodes of syncope. With symptoms, telemetry revealed a rapid monomorphic rhythm (panel A) consistent with ventricular tachycardia (VT). ECG and cardiac markers were unremarkable. Echocardiography revealed an apical defect emptying into a large thin-walled chamber (panels B, C, D). Doppler interrogation revealed bidirectional flow between the left ventricle (LV) and this chamber, consistent with true aneurysm of the LV apex versus contained rupture of the LV apex with pseudoaneurysm formation. Cardiac catheterisation showed a 40% plaque in the mid left anterior descending coronary artery. At cardiac surgery, the abnormality was resected and the LV repaired with a pericardial patch. Recovery was uneventful with no further VT on telemetry and no VT inducible at electrophysiology study. Pathological examination of the resected tissue revealed true aneurysm with surviving myocytes scattered throughout areas of scar. Aetiology was likely an old myocardial infarction, caused by left anterior descending coronary artery thrombosis or spasm at the site of a focal and intrinsically non-obstructive plaque.
Differentiation of true aneurysm from pseudoaneurysm by echocardiography can be difficult. Here, true aneurysm was indicated by the presence of continuous endomyocardial and pericardial layers extending from the normal portion of the left ventricle throughout the aneurysmal sac. Aneurysms of the left ventricle, often associated with ventricular arrhythmias, typically form by dilation of infarct or infarct scars, although congenital and inflammatory aneurysms have been described. Resection of the aneurysm and surrounding abnormal myocardium can cure the ventricular arrhythmias, as in this case.
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