Left ventricular pseudoaneurysm

Background

• Acute MI or surgical mishap causes ventricular free wall rupture
  • Contained by pericardial adhesions
  • Mortality rate high secondary to rupture of pseudoaneurysm

Causes

• Transmural MI (anterior or inferior most common)
• Surgical mishap

Clinical Features

• 10% are asymptomatic
• History of MI or cardiac surgery
• Symptoms similar to congestive heart failure
  • Angina
  • Shortness of breath
• New cardiac murmur (70%)

Differential Diagnosis

ST Elevation

• Cardiac
  • ST-segment elevation myocardial infarction (STEMI)
  • Post-MI (ventricular aneurysm pattern)
  • Previous MI with recurrent ischemia in same area
  • Wellens' syndrome
  • Coronary artery vasospasm (eg, Prinzmetal's angina)
  • Coronary artery dissection
  • Pericarditis
  • Myocarditis
  • Aortic dissection in to coronary
  • Left ventricular aneurysm
  • Left ventricular pseudoaneurysm
  • Early repolarization
  • Left bundle branch block
  • Left ventricular hypertrophy (LVH)
  • Myocardial tumor
  • Myocardial trauma
  • RV pacing (appears as Left bundle branch block)
  • Brugada syndrome
  • Takotsubo cardiomyopathy
  • AVR ST elevation
• Other thoracic
  • Pneumomediastinum
  • Pneumothorax
  • Pulmonary embolism
• Metabolic
  • Drugs of abuse (eg, cocaine, crack, meth)
    • Cocaine chest pain
  • Hyperkalemia (only leads V1 and V2)
  • Hypothermia ("Osborn J waves")
• Medications
  • Tricyclic (TCA) toxicity
  • Digoxin

Evaluation

• ECG
  • Non-specific ST changes
  • ST elevation (20%)
• CXR
  • Mass-like appearance
• LV angiography

Management

• Surgical repair = 10% 5 yr mortality
• Medical therapy = 50% 5 yr mortality

Complications

• Angina (increased O2 demand)
• Complete LV rupture

See Also

• Left ventricular aneurysm