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Left Ventricular Pseudoaneurysm: A Rare Cause of Chest Pain to Keep in Mind

      A man in his 80s presented with sharp central chest pain, diaphoresis, and dyspnea. He had a remote history of coronary artery bypass graft. Results of the physical examination were unremarkable, and initial vital signs were stable. Electrocardiogram was unrevealing. Troponins were elevated and flat. He was initiated on intravenous nitroglycerin, after which his symptoms resolved. However, his blood pressure decreased to a minimal systolic of 76 and diastolic of 50 mm Hg. Because of the resolution of his symptoms, immediate angiography was deferred, and the patient was admitted to the cardiac intensive care unit. Transthoracic echocardiography (TTE) showed a loculated pericardial fluid collection adjacent to the anterolateral left ventricular (LV) wall (Figure; Video 1, available online at http://www.mayoclinicproceedings.org). Contrast TTE showed extension of the contrast from the main LV cavity to the adjacent pericardial cavity, consistent with pseudoaneurysm (Figure; Video 2, available online at http://www.mayoclinicproceedings.org). Computed tomography angiography of the thoracic aorta confirmed LV myocardial rupture along the anterolateral wall with active extravasation of contrast (Supplemental Figure 1A-D, available online at http://www.mayoclinicproceedings.org). The patient’s hospital stay was complicated by acute kidney injury. In the setting of increased risk for dialysis, he opted for conservative management. He remained hemodynamically stable, and pericardiocentesis was not indicated. He was discharged 1 week later. Predismissal TTE redemonstrated the contained LV anterolateral wall rupture with systolic and end-diastolic flow through the myocardial defect (Supplemental Figure 2; Video 3, available online at http://www.mayoclinicproceedings.org). He did well after discharge and died 4 years later of metastatic bladder cancer.
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      FigureTransthoracic echocardiography demonstrating left ventricular free-wall rupture. (A) Short axis view at the level of papillary muscles showing a loculated pericardial cavity to the anterolateral wall of left ventricle (green arrow). (B-D) Apical views with contrast showing extension of the contrast agent from the left ventricular main cavity to the pericardial cavity (green arrows) are consistent with left ventricular free-wall rupture and pseudoaneurysm formation.
      Left ventricular pseudoaneurysms develop when LV free-wall rupture is contained by adherent pericardium or scar tissue and is most commonly secondary to myocardial infarction.
      • Frances C.
      • Romero A.
      • Grady D.
      Left ventricular pseudoaneurysm.
      Mortality rate is high both with surgically (23%) and medically (48%) managed patients. Our patient’s previous cardiac surgery was thought to provide him with protection against complete rupture owing to scar tissue formation along the pericardium.

      Potential Competing Interests

      The authors have no competing interests.

      Supplemental Online Material

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      Supplemental Figure 1Computed tomography angiography of the thoracic aorta and coronary arteries confirming left ventricular anterolateral wall rupture and pseudoaneurysm formation with active extravasation of contrast into a contained cavity (green arrows) as shown in axial (A), coronal (B), and sagittal views (C), as well as in reconstructed 3-dimensional view (D).
      Figure thumbnail figs2
      Supplemental Figure 2Predismissal transthoracic echocardiography demonstrating contained left ventricular anterolateral wall rupture with systolic flow through the myocardial defect (green arrow).

      Reference

        • Frances C.
        • Romero A.
        • Grady D.
        Left ventricular pseudoaneurysm.
        J Am Coll Cardiol. 1998; 32: 557-561https://doi.org/10.1016/s0735-1097(98)00290-3