LV Pseudoaneurysm: A Rare and Life-Threatening Disorder

Introduction

LV pseudoaneurysm is a rare but life-threatening disorder that is often reported as a complication of myocardial infarction or cardiac surgery. It is characterized by an outpouching of the left ventricular wall, which is contained by adherent pericardium or scar tissue, without involving any myocardial tissue. This condition poses a significant risk of rupture, making early diagnosis and appropriate management crucial for patient outcomes.

In this article, we will explore the case of a patient who presented with atypical symptoms and was diagnosed with LV pseudoaneurysm. We will also delve into the available approaches to diagnosis and management in these patients, highlighting the importance of vigilance and a high index of suspicion in detecting this stealthy killer.

Case Presentation

A 69-year-old African American male with a complex medical history presented with a 2-week history of nonexertional atypical left chest pain. The patient had no prior risk factors for LV pseudoaneurysm and had recently undergone a deceased-donor kidney transplant.

The patient’s pain was described as nonradiating, intermittent, and moderate in severity. He had previously sought medical attention for light-headedness and was found to be orthostatic hypotensive. His blood pressure medications were adjusted, improving his dizziness. He also self-medicated with antireflux medications, which provided some relief for his chest pain.

Upon admission, the patient’s vital signs were stable, and the physical examination was unremarkable. Cardiac panel results, including troponin T and creatine kinase-MB levels, were normal. An electrocardiogram (ECG) showed sinus rhythm.

To further investigate the refractory chest pain, the patient underwent cardiac catheterization, which ruled out significant obstruction in the coronary arteries. Left ventriculogram showed no wall motion abnormality. However, a subsequent transthoracic echocardiography revealed an unexpected outpouching of the basal inferoseptal wall of the left ventricle.

Diagnosis and Management

Noninvasive imaging modalities such as echocardiography, computed tomography angiogram, and cardiac magnetic resonance imaging (CMRI) play a crucial role in the diagnosis of LV pseudoaneurysm. Echocardiography, in particular, is effective in identifying the characteristic features of a pseudoaneurysm, including a narrow neck and wide apex.

Medical therapy can be considered in asymptomatic patients with small-sized outpouchings (<3 cm). Regular follow-up is essential to monitor the dimensions of the pseudoaneurysm and detect any progression. In symptomatic patients with giant aneurysms or those at a high risk of rupture, surgical intervention is recommended.

In recent years, percutaneous-device closure has emerged as a new therapeutic approach for LV pseudoaneurysm. This method is particularly beneficial for patients who are deemed high risk for surgery or require a redo cardiovascular procedure. It offers a low risk of complications such as massive rupture, thromboembolism, and cardiac failure.

Clinical Presentation and Risk Factors

The clinical presentation of LV pseudoaneurysm can be nonspecific, making diagnosis challenging. Symptoms may include congestive heart failure, chest pain, dyspnea, arrhythmia, and even sudden cardiac arrest. However, some patients may remain asymptomatic, further complicating the detection of this condition.

LV pseudoaneurysm is often associated with myocardial infarction, cardiac surgery, infection, trauma, or other rare conditions. A systematic literature review revealed that myocardial infarction (55%), surgery (33%), and trauma (7%) were the top three associations with LV pseudoaneurysm. The risk of rupture is significantly higher in pseudoaneurysms compared to true aneurysms, necessitating prompt management.

Pathogenesis and Differentiation

The exact pathogenesis of LV pseudoaneurysm is not fully understood. It is believed to occur when a small weak part of the cardiac wall, typically a transmural infarct, ruptures and forms a narrow orifice over time. This orifice connects the ventricular cavity with the potential space beneath the pericardium, resulting in blood flow to-and-fro and subsequent accumulation within the pericardium or pericardial adhesions.

Differentiating LV pseudoaneurysm from true aneurysms can be challenging, as both conditions present with similar clinical findings. True ventricular aneurysms involve the endocardium and myocardium, while pseudoaneurysms are contained by the pericardium, pericardial adhesions, or a thrombus. Imaging techniques, such as transthoracic echocardiography, transesophageal echocardiography, ventricular angiography, and CMRI, play a crucial role in distinguishing between the two conditions.

Importance of Early Diagnosis and Treatment

Early diagnosis is paramount in the management and prognosis of patients with LV pseudoaneurysm. Transthoracic echocardiography and CMRI are particularly valuable in detecting and evaluating the extent of the pseudoaneurysm. Prompt intervention, either through surgical closure or percutaneous-device closure, can significantly reduce the risk of rupture and improve patient outcomes.

Medical therapy may be considered in select cases, especially for asymptomatic patients with small-sized pseudoaneurysms. Regular follow-up is essential to monitor the dimensions of the pseudoaneurysm and assess any changes over time.

Conclusion

LV pseudoaneurysm is a rare but serious clinicopathologic entity that requires prompt diagnosis and appropriate management. Vigilance and a high index of suspicion are crucial in detecting atypical presentations of this condition. Noninvasive imaging modalities, such as echocardiography and CMRI, play a pivotal role in diagnosis, while surgical intervention and percutaneous-device closure offer viable treatment options.

Physicians should be aware of the risk factors and clinical presentations associated with LV pseudoaneurysm, as early intervention can significantly reduce the risk of rupture and improve patient outcomes. By staying informed and vigilant, healthcare professionals can effectively manage this life-threatening disorder and provide optimal care to their patients.

Additional Information: LV pseudoaneurysm can be a challenging condition to diagnose due to its nonspecific symptoms and rare occurrence. By increasing awareness and knowledge about this condition, healthcare professionals can ensure early detection and prompt management, ultimately saving lives.