Post-Traumatic Giant Left Ventricular Pseudoaneurysm: a Multimedia Presentation

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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 ruptures^2-4. 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).

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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).

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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 performed^6,7,8.

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.

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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.

References

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