[ Table Omitted - see PDF ]
Abbreviations, acronyms & symbols CPB = Cardiopulmonary bypass LV = Left ventricle LVP = Left ventricular pseudoaneurysm MRI = Magnetic resonance imaging
INTRODUCTION
Left ventricular pseudoaneurysms (LVP) form in the presence of a cardiac rupture contained by surrounding structures, like the pericardium or scar tissue1. Thus, unlikely true aneurysms, a LVP contains no endocardium or myocardium, being more propense to ruptures2-4. Trauma is a rare cause, given the high mortality in this scenario5.
Because patients frequently present with nonspecific symptoms, a high index of suspicion is needed to make the diagnosis. Whereas electrocardiography and chest X-ray abnormalities are almost always present, they are also usually nonspecific1.
This is the report of the investigation and treatment of a case of penetrating thoracic trauma by stab with initial surgical repair evolving to a giant LVP after five years of indolent evolution.
PATIENT CHARACTERIZATION
Clinical Data
A 34-year-old female, inmate, reported intermittent episodes of exercise-related chest pain and mild dyspnea. The patient reported a traumatic stab injury in the chest five years before that underwent surgery with suture of pulmonary and myocardial lacerations.
In the physical examination, patient had blood pressure and heart rate between normal values with a regular two-stroke heart rhythm. Continuous 4+/6+ murmur with fremitus and cervical irradiation were noted.
Radiography
Mediastinal mass with left cardiac silhouette lost and opacification of the retrosternal space is shown (Figure 1).
[ Image Omitted - see PDF ]
Transthoracic Echocardiography with Doppler Evaluation
Moderate dilatation of left ventricle (LV) with a large pseudoaneurysm in the mid-anterior wall. Severe ejection fraction impairment (31%) with mid-anterior and apical anterior hypokinesis (Video 1). Bidirectional flow is seen between the LV and the pseudoaneurysm cavity (Video 2).
[ Image Omitted - see PDF ] [ Image Omitted - see PDF ] [ Image Omitted - see PDF ]
Clinical Follow-up
Another cardiac MRI was made six months latter showing a minimal residual cavity without signs of complication. After surgery, the patient had a good postoperative evolution without complications, being discharged from hospital after 11 days. She is at clinical and imaging follow-up, with a two-year evolution, without worsening of symptoms.
DISCUSSION
The incidence of LVP is low and most of the cases are related to acute myocardial infarction, cardiac surgery, and trauma. LVP have become a rare complication of acute myocardial infarction, occurring in approximately 2% of the cases or less, when thrombolytic or primary percutaneous intervention can be performed6,7,8.
The natural history of surgically treated and untreated LVP is not clearly defined9 and data to guide the treatment are scarce10. Surgical repair is the recommended treatment, given the pseudoaneurysms’ propensity for life-threatening complications, such as cardiac tamponade and shock. Untreated pseudoaneurysms have a 30% to 45% risk of rupture and the surgical repair of post-traumatic LVP has a reported mortality of > 7%.
Is this article, it is reported an unusual case of post-traumatic giant LVP with an indolent evolution, although all the potential risks of rupture.
[ Table Omitted - see PDF ]
Authors' roles & responsibilities DTW Drafting the work or revising it critically for important intellectual content; final approval of the version to be published MKS Drafting the work or revising it critically for important intellectual content; final approval of the version to be published AS Drafting the work or revising it critically for important intellectual content; final approval of the version to be published AJR Drafting the work or revising it critically for important intellectual content; final approval of the version to be published PRBE Substantial contributions to the conception or design of the work; drafting the work or revising it critically for important intellectual content; final approval of the version to be published
* This study was carried out at the Centro de Ciências das Imagens e Física Médica, Hospital das Clínicas da Faculdade de Medicina de Ribeirão Preto - Universidade de São Paulo (HCFMRP-USP), Ribeirão Preto, SP, Brazil.
1 Frances C, Romero A, Grady D. Left ventricular pseudoaneurysm. J Am Coll Cardiol. 1998;32(3):557-61. doi:10.1016/s0735-1097(98)00290-3.» https://doi.org/10.1016/s0735-1097(98)00290-3
2 Vlodaver Z, Coe JI, Edwards JE. True and false left ventricular aneurysms. Propensity for the altter to rupture. Circulation. 1975;51(3):567-72. doi:10.1161/01.CIR.51.3.567.» https://doi.org/10.1161/01.CIR.51.3.567
3 Zoffoli G, Mangino D, Venturini A, Terrini A, Asta A, Zanchettin C, et al. Diagnosing left ventricular aneurysm from pseudo-aneurysm: a case report and a review in literature. J Cardiothorac Surg. 2009;4(1):11. doi:10.1186/1749-8090-4-11.» https://doi.org/10.1186/1749-8090-4-11
4 Bisoyi S, Dash AK, Nayak D, Sahoo S, Mohapatra R. Left ventricular pseudoaneurysm versus aneurysm a diagnosis dilemma. Ann Card Anaesth. 2016;19(1):169-72. doi:10.4103/0971-9784.173042.» https://doi.org/10.4103/0971-9784.173042
5 Mulder DG. Stab Wound Of The Heart. Ann Surg. 1964;160:287-91. doi:10.1097/00000658-196408000-00017.» https://doi.org/10.1097/00000658-196408000-00017
6 Hsu YH, Chiu IS, Chien CT. Left ventricular pseudoaneurysm diagnosed by magnetic resonance imaging in a nine-year-old boy. Pediatr Cardiol. 1993;14(3):187-90. doi:10.1007/BF00795654.» https://doi.org/10.1007/BF00795654
7 Bhardwaj R, Sondhi S, Mehta A. Unruptured giant left ventricular pseudoaneurysm after silent myocardial infarction. BMJ Case Rep. 2018; pii: bcr-2018-225812. doi:10.1136/bcr-2018-225812.» https://doi.org/10.1136/bcr-2018-225812
8 Irazusta FJ, Ramirez U, Caro-Codon J, Refoyo E, Garrido D, Pinilla I, et al. Extensive chest wall destruction secondary to a large ventricle pseudoaneurysm: a surgical challenge. Ann Thorac Surg. 2017;103(3):e227-9. doi:10.1016/j.athoracsur.2016.09.007.» https://doi.org/10.1016/j.athoracsur.2016.09.007
9 Hulten EA, Blankstein R. Pseudoaneurysms of the heart. Circulation. 2012;125(15):1920-5. doi:10.1161/CIRCULATIONAHA.111.043984.» https://doi.org/10.1161/CIRCULATIONAHA.111.043984
10 Gigase A, Spapen J, Penicka M, Van Camp G. Giant pseudoaneurysm of the left ventricle. Int J Cardiovasc Imaging. 2019; 35(6):1161-2. doi:10.1007/s10554-019-01558-0.» https://doi.org/10.1007/s10554-019-01558-0
Wada, Danilo Tadao: Universidade de São Paulo
Koenigkam-Santos, Marcel: Universidade de São Paulo
Schmidt, André: Universidade de São Paulo
Rodrigues, Alfredo José: Universidade de São Paulo
Evora, Paulo Roberto B.: Universidade de São Paulo
You have requested "on-the-fly" machine translation of selected content from our databases. This functionality is provided solely for your convenience and is in no way intended to replace human translation. Show full disclaimer
Neither ProQuest nor its licensors make any representations or warranties with respect to the translations. The translations are automatically generated "AS IS" and "AS AVAILABLE" and are not retained in our systems. PROQUEST AND ITS LICENSORS SPECIFICALLY DISCLAIM ANY AND ALL EXPRESS OR IMPLIED WARRANTIES, INCLUDING WITHOUT LIMITATION, ANY WARRANTIES FOR AVAILABILITY, ACCURACY, TIMELINESS, COMPLETENESS, NON-INFRINGMENT, MERCHANTABILITY OR FITNESS FOR A PARTICULAR PURPOSE. Your use of the translations is subject to all use restrictions contained in your Electronic Products License Agreement and by using the translation functionality you agree to forgo any and all claims against ProQuest or its licensors for your use of the translation functionality and any output derived there from. Hide full disclaimer
© 2020. This work is published under https://creativecommons.org/licenses/by/4.0/ (the “License”). Notwithstanding the ProQuest Terms and Conditions, you may use this content in accordance with the terms of the License.
Abstract
Trauma is a rare cause, given the high mortality in this scenario5. Because patients frequently present with nonspecific symptoms, a high index of suspicion is needed to make the diagnosis. In the physical examination, patient had blood pressure and heart rate between normal values with a regular two-stroke heart rhythm. [ Table Omitted - see PDF ] Authors' roles & responsibilities DTW Drafting the work or revising it critically for important intellectual content; final approval of the version to be published MKS Drafting the work or revising it critically for important intellectual content; final approval of the version to be published AS Drafting the work or revising it critically for important intellectual content; final approval of the version to be published AJR Drafting the work or revising it critically for important intellectual content; final approval of the version to be published PRBE Substantial contributions to the conception or design of the work; drafting the work or revising it critically for important intellectual content; final approval of the version to be published * This study was carried out at the Centro de Ciências das Imagens e Física Médica, Hospital das Clínicas da Faculdade de Medicina de Ribeirão Preto - Universidade de São Paulo (HCFMRP-USP), Ribeirão Preto, SP, Brazil. 1 Frances C, Romero A, Grady D. Left ventricular pseudoaneurysm.
You have requested "on-the-fly" machine translation of selected content from our databases. This functionality is provided solely for your convenience and is in no way intended to replace human translation. Show full disclaimer
Neither ProQuest nor its licensors make any representations or warranties with respect to the translations. The translations are automatically generated "AS IS" and "AS AVAILABLE" and are not retained in our systems. PROQUEST AND ITS LICENSORS SPECIFICALLY DISCLAIM ANY AND ALL EXPRESS OR IMPLIED WARRANTIES, INCLUDING WITHOUT LIMITATION, ANY WARRANTIES FOR AVAILABILITY, ACCURACY, TIMELINESS, COMPLETENESS, NON-INFRINGMENT, MERCHANTABILITY OR FITNESS FOR A PARTICULAR PURPOSE. Your use of the translations is subject to all use restrictions contained in your Electronic Products License Agreement and by using the translation functionality you agree to forgo any and all claims against ProQuest or its licensors for your use of the translation functionality and any output derived there from. Hide full disclaimer