Posttraumatic left ventricular pseudoaneurysm due to intramyocardial dissecting hematoma

Ventricular septal intramyocardial dissection after cardiac tumor excision

We reported a rare case: an infant underwent cardiac tumor resection, and postoperative transthoracic echocardiography revealed a cystic dissection located in the interventricular septum.

Intracardiac hematoma treated conservatively by ECMO support

Clinical pathway of an intracardiac hematoma treated by ECMO support.

Post-Interventionelle subendokardiale “Tamponade“ bei okkulter Koronarperforation während einer komplexen PTCA

Bei einem Patienten mit 3-Gefäß-Erkrankung und Zustand nach aortokoronarer Bypassoperation vor 10 Jahren mit LIMA-Bypass auf LAD und Venenbypass auf RCA wurde bei akuter Dyspnoesymptomatik mit atemabhängigen Beschwerden und erhöhten D-Dimeren zum Ausschluss einer Lungenarterienembolie (LAE) eine Computertomografie (CT 1) durchgeführt und eine LAE ausgeschlossen. Bei fortbestehender Beschwerdesymptomatik und bekannter KHK (koronarer Herzkrankheit) wurde am Folgetag eine Koronarangiografie durchgeführt. Es wurde eine PTCA und Stentimplantation mit sequenzieller Vordilatation der proximalen und der mittleren RCA durchgeführt. Primär zeigte sich ein gutes Ergebnis bei schwierigem PTCA-Verlauf bei ausgeprägter Verkalkung und torquiertem Gefäßverlauf. Noch im Herzkatheterlabor erfolgte das Loading mit Aspirin und Clopidogrel. Nach Beendigung der Untersuchung wurde ein Perikarderguss echokardiografisch ausgeschlossen. Im Rahmen einer Routine-Echokardiografie vor Entlassung zeigte sich eine ausgeprägte echoarme Raumforderung im rechten Ventrikel, die fast das gesamte Ventrikelvolumen ausfüllte, mit Aussparung nur eines kleinen basalen Bereiches. Weder im ersten TTE nach Intervention noch in der initialen CT-Untersuchung (CT 1) war diese Raumforderung nachweisbar. Klinisch blieb der Patient beschwerdefrei. Im dann durchgeführten Kardio-CT (CT 2) und im Kardio-MRT sowie in der transösophagealen Echokardiografie bestätigte sich diese Raumforderung im rechten Ventrikel, welche eine subendokardiale und intramurale Ausbreitung zeigte. Zusammenfassend (Vergleich CT 1 vs. CT 2) zeigte sich somit eine postinterventionelle Tamponade ohne hämodynamische Relevanz am ehesten im Rahmen einer Gefäßverletzung durch den Koronardraht mit aufgetretener okkulter Koronarperforation. Somit können Mikrokoronarperforationen auch im weiteren Verlauf über Tage zu intramuralen Einblutungen (gegenwärtiger Fall) oder zur Ausbildung eines Perikardergusses führen. Echokardiografische Kontrolluntersuchungen auch mehr als 24 Stunden nach Koronarintervention bei komplexen Prozeduren können helfen, diese rechtzeitig zu erkennen. Auch größere intramurale Einblutungen können konservativ beherrschbar bleiben.

Idiopathic right ventricular pseudoaneurysm presenting with ventricular tachycardia: a case report

Right ventricular (RV) pseudoaneurysm is very rare and is seen after penetrating chest trauma, cardiac surgery, infective endocarditis, myocardial infarction, syphilis, endomyocardial biopsy, lead extraction. Idiopathic right ventricular pseudoaneurysm is even rarer. They have varied presentations depending on the etiology. Diagnosis is usually made by echocardiography. We present a case of 21-year-old male who presented to us with palpitations for 2 days and one episode of syncope and was diagnosed with monomorphic ventricular tachycardia (VT) and he was managed with electrical cardioversion during one of the episodes. Echocardiogram and CMR showed a larger right ventricular pseudoaneurysm at apex. Surgical excision was done uneventfully. The patient had no further VT episodes post-surgery. This case highlights the approach to diagnosis and management of RV pseudoaneurysm.

Intramyocardial dissecting haematoma mimicking left ventricular clot, a rare complication of myocardial infarction: a case report

Background

Intramyocardial dissecting haematoma is a rare complication of myocardial infarction (MI) associated with high mortality rates. Studies and research of this occurrence are limited largely to isolated case reports or case series.

Case summary

We report a case of late presenting MI, where on initial echocardiogram had what was thought to be an intraventricular clot. However, upon further evaluation, the patient actually had an intramyocardial haematoma, with the supporting echocardiographic features to distinguish it from typical left ventricular (LV) clot. While this prevented the patient from receiving otherwise unnecessary anticoagulation, this diagnosis also put him at a much higher risk of mortality. Despite exhaustive medical and supportive management, death as consequence of pump failure occurred after 2 weeks.

Discussion

This report highlights the features seen on echocardiography which support the diagnosis of an intramyocardial haematoma rather than an LV clot, notably the various acoustic densities, a well visualized myocardial dissecting tear leading into a neocavity filled with blood, and an independent endocardial layer seen above the haematoma. Based on this report, we wish to highlight the importance of differentiating intramyocardial haematomas from intraventricular clots in patients with recent MI.

A dissecting aneurysm of interventricular septum resulting from congenital coronary artery fistula

RATIONALE

Ventricular septal dissecting aneurysms are rarely caused by congenital coronary artery fistulas.

PATIENT CONCERNS

We present a rare case of ventricular septal dissecting aneurysm that resulted from a congenital coronary artery fistula in a 41-year-old female patient with the complaint of chest pain.

DIAGNOSIS

Ventricular septal dissecting aneurysm resulting from a right coronary artery fistula.

INTERVENTIONS

The patient was advised to receive transcatheter interventional therapy in the department of cardiology.

OUTCOMES

It was difficult for the cardiac catheter to reach the orifice of fistula due to the long and circuitous nature of the right coronary artery, which ultimately resulted in abandoning interventional fistula occlusion therapy. The patient finally decided to undergo surgical treatment in Shanghai and the symptoms have been markedly improved after hemodynamic correction.

LESSONS

The right coronary artery was the dominant vessel and the fistula was located in the distal part of the posterior descending branch of right coronary artery. Hence, transcatheter closure was appropriate; however, due to the fact that right coronary artery was too long and circuitous, the length of cardiac catheter was relatively insufficient. For this reason, a comprehensive and careful assessment before the operation is necessary.

Intramyocardial Dissecting Hematoma in Patients with Ischemic Cardiomyopathy: Role of Multimodality Imaging in Three Patients Treated Conservatively

•IDH is an infrequent complication of myocardial infarction. •IDH can be diagnosed with echocardiography and multimodality imaging. •Conservative management is a viable option in patients with poor LVEF and DCM.

Dissecting ventricular pseudoaneurysm after perimyocarditis-a case report

BACKGROUND

The current case describes the fast development of a pseudoaneurysm in a patient that presented with signs of systemic inflammation and generally deranged blood work.

CASE PRESENTATION

The pseudoaneurysm appeared within one week of disease onset. The anatomic extent of the pseudoaneurysm was unusual, as it dissected intramurally beneath the septum, inferior to the right ventricle and had effect on the RV filling. The etiology could not be definitely defined, since in adults the most common cause for pseudoaneurysm development is recent myocardial infarction, but in this patient the coronary arteries were healthy. Instead it could have been a consequence of an aggressive perimyocarditis.

CONCLUSIONS

Due to the unpredictable nature of pseudoaneurysms we advocate early contact with a center with cardiothoracic surgery expertise for rapid surgical intervention.

Spontaneous obliteration of right ventricular pseudoaneurysm after blunt chest trauma: diagnosis and follow-up with multidetector CT

Right ventricular (RV) pseudoaneurysm caused by trauma is very rare. We report a case of RV pseudoaneurysm which resolved without surgical treatment in a patient who survived a falling accident. Echocardiography failed to identify the pseudoaneurysm. Electrocardiography-gated CT showed a 17-mm-sized saccular pseusoaneurysm arsing from the RV outflow tract with a narrow neck. Follow-up CT after two months showed spontaneous obliteration of the lesion.

Giant pseudoaneurysm of the left ventricular outflow tract: a rare disease

Pseudoaneurysm of the left ventricular outflow tract (LVOT) is a rare disease with high morbidity and mortality, resulting from left ventricular damage due to myocardial infarction, infective endocarditis or surgical trauma. A case of giant pseudoaneurysm of the LVOT, even more rarely reported in the literature, is described. The lesion was detected 12 years after aortic valve replacement for infective endocarditis in a young patient, a former intravenous drug user. As it is an uncommon disease, little is known about its clinical presentation and treatment.

Late simultaneous presentation of left ventricular pseudoaneurysm and tricuspid regurgitation after blunt chest trauma

A 32-yr-old man developed progressive exertional dyspnea 4 yr after blunt chest trauma due to an automobile accident. Two-dimensional echocardiography and computed-tomographic coronary angiography demonstrated a large pseudoaneurysm of the left ventricle and severe tricuspid regurgitation. The patient underwent successful surgical exclusion of the pseudoaneurysm by endoaneurysmal patch closure and repair of the tricuspid valve regurgitation. To the best of our knowledge, this is the first case of these 2 different pathologies presenting late simultaneously after blunt chest trauma and successful surgical repairs in the published literature.

Multidetector computed tomography in post-traumatic ventricular pseudoaneurysm

We report a 20-year-old male with rare asymptomatic aneurysm of the left ventricle that was concluded to be a pseudoaneurysm given its calcified walls and the history of severe blunt chest trauma 8 years ago. Multidetector computed tomography (CT) angiography of the coronary vessels helped exclude vascular insult and suggest traumatic intramyocardial dissection as underlying etiopathogenesis, besides providing a good view of aneurysm and cardiac morphology in relation to coronary vessels.

Intramyocardial dissecting haematoma: a rare complication of acute myocardial infarction

Intramyocardial dissecting haematoma (IDH) is a rare complication of myocardial infarction, with very scarce reports in medical literature. Before the advent of non-invasive imaging techniques, the diagnosis of IDH was only made by necropsy. It can develop in the left ventricular free wall, the right ventricle, or the interventricular septum. We present a case of a patient with an IDH after acute anterolateral myocardial infarction, focusing on the utility of echocardiography in the diagnosis and follow-up of this unusual complication. By this imaging modality, it was possible to see the various acoustic densities of the progressive clotting of the intramyocardial haematoma, its extension through the haemorrhagic dissection, as well as its independency in relation to ventricular cavities and extracardiac space by confirming intact epicardial and endocardial layers. Based on this report, we believe that serial two-dimensional echocardiography, added, when necessary, by the use of contrast agents is the non-invasive method ideally suited to confirm the diagnosis and monitor its evolution at the patient's bedside.

Posttraumatic ventricular pseudoaneurysm in a 7-year-old child diagnosed with multidetector CT of the chest: a case report

We report the CT findings on a 7-year-old male who developed a left ventricular pseudoaneurysm involving the anterior septal left ventricular wall after blunt chest trauma.

Surgical treatment of postinfarction left ventricular pseudoaneurysm

BACKGROUND

Left ventricular pseudoaneurysm from myocardial infarction is rare and is associated with a high risk of rapid enlargement and rupture. The purposes of this study were to describe its clinical presentation, assess the accuracy of diagnostic imaging modalities, and determine operative and late surgical results.

METHODS

From January 1986 through December 2001, 30 patients aged 50 to 85 years (mean, 68; 70% male) underwent left ventricular pseudoaneurysm repair. Two surgical approaches were used: primary repair (n = 5, 17%) and patch closure (n = 25, 83%). Twenty-one patients (70%) had concomitant procedures, including coronary revascularization (n = 17, 57%) and mitral valve surgery (n = 9, 30%); 8 patients (29%) underwent emergent surgery. Clinical presentation, preoperative imaging data, and surgical outcomes were abstracted from medical records or obtained by patient follow-up.

RESULTS

The most common clinical presentations were heart failure (n = 22, 73%) and angina (n = 11, 41%). Pseudoaneurysm was rarely suspected at clinical presentation. Contrast ventriculography was diagnostic in 54% of patients in whom it was performed, as opposed to 97% for two-dimensional echocardiography (p = 0.2). Postoperative intra-aortic balloon pump was required in 7 patients (23%). Hospital mortality was 20%, and late survival was 73%, 59%, and 45% at 1, 5, and 8 years, respectively.

CONCLUSIONS

Left ventricular pseudoaneurysm should be suspected in postinfarction patients with unexplained heart failure. Echocardiography is usually diagnostic and is superior to ventriculography. The surgical mortality rate is elevated in this complex patient population. Long-term survival is also poor, mainly because of underlying ischemic cardiomyopathy.

Traumatic Intramyocardial Left Ventricular Dissection: A Case Report

In this report, we present an unusual case of a patient who sustained and survived an intramyocardial dissecting hematoma with subacute ventricular rupture complicating a motor vehicle accident. In conclusion, we report on the diagnosis, management, and prior literature of this highly unusual and often lethal condition.

Surgical treatment of postinfarction left ventricular pseudoaneurysm

In this report, we present two cases who had left ventricular pseudoaneurysm, resection, and repair was done successfully. The repair was performed with the aid of cardiopulmonary bypass. The neck of the pseudoaneurysm was closed with autologous fresh pericardial patch. The surgical treatment of ventricular pseudoaneurysm depends upon their origin, size, and local extension.

Spontaneous Retraction of an Intramyocardial Dissecting Hemorrhage and Multiple Left Ventricular Thrombus Formations in Subacute Myocardial Infarction and Antiphospholipid Syndrome: A Case Report with Long-term Follow-up

This report describes a 68-year-old patient with a subacute myocardial infarction and antiphosholipid syndrome. He developed an intramyocardial dissecting hemorrhage involving the left ventricular apex and multiple left ventricular thrombus formations, documented by contrast echocardiography and magnetic resonance imaging. By use of transthoracic echocardiography, spontaneous retraction of the dissecting hemorrhage could be detected. Severe coronary 3-vessel disease was successfully treated by coronary artery bypass grafting. During follow-up of 16 months, the dissecting hematoma could not been detected. Under initiation of anticoagulant treatment with Coumadin, the patient was in stable clinical condition and improved in New York Heart Association class from III to II. The pathophysiology, diagnosis, and management of this potentially highly lethal complication is reviewed.

Spontaneous intramyocardial hematoma mimicking a cardiac tumor of the right ventricle

Intramyocardial hematoma is an uncommon entity and may occur after myocardial infarction, coronary balloon angioplasty, cardiac operation, or chest trauma. It has even been noted to occur spontaneously. This report describes a 62-year-old woman who presented with a recent exacerbation of exertional dyspnea and without a history of chest pain or trauma. Echocardiography and computerized tomography revealed a large intramyocardial hematoma of the right ventricle, masquerading as a cardiac tumor. The accurate diagnosis was finally made at the time of surgical intervention.

[Conservative management of a post infarction intramyocardial dissecting hematoma]

Intramyocardial dissecting hematoma is an infrequent complication of subacute myocardial infarction. Pathological findings consist of a cavity filled with blood, the outer wall of which is the myocardium and pericardium and the inner wall, which faces the ventricular cavity, is part of the myocardium and endocardium. There is scarce information on the subject and the management of these patients continues to be debated. However, there is a certain preference for surgical repair of the defect. Cases in which conservative treatment is a therapeutic option have been reported. We report the case of a patient with an intramyocardial dissecting hematoma after acute anterolateral myocardial infarction who was treated conservatively and achieved a satisfactory outcome in the intermediate-to-long term period.

Myocardial contusion culminating in a ruptured pseudoaneurysm of the left ventricle--a case report

Blunt chest trauma continues to be one of the most common injuries at all ages. Trauma in general is the leading cause of death in the young to middle-aged segment of our population. Blunt chest injury is said to occur in more than one third of all motor vehicle accidents. Myocardial contusion is the most frequent cardiac injury resulting from blunt chest trauma. Autopsy studies indicate that cardiac trauma was directly associated with death in approximately 10% of cases suffering blunt chest injury. Aneurysm formation as a sequela of blunt cardiac trauma is a rare entity and pseudoaneurysm formation is considerably more rare. A case of myocardial contusion resulting in myocardial necrosis, rupture of the ventricle, and pseudoaneurysm formation with subsequent rupture and sudden death is presented.

Spontaneous closure (thrombosis) of the intramyocardial dissection: 40-month follow-up

Intramyocardial dissection is an uncommon complication of a myocardial infarction or blunt chest trauma created by a hematoma located between the layers of myocardial fibers. This report describes the clinical course, 2-dimensional, and 3-dimensional echocardiographic findings of an unusual case of the intramyocardial dissection.

Repair of ventricular septal defect and left ventricular aneurysm following blunt chest trauma

In children, even minor trauma to the chest can result in cardiac injury. We describe a case of a 13-year-old boy who received blunt chest trauma during a motorcycle accident. He was initially symptom-free but later complained of persistent chest pain and a murmur was noted. An anterior muscular ventricular septal defect was detected one day after the accident, and a left ventricular pseudo-aneurysm developed days later. Both were successfully repaired 3 weeks after the injury.

Intramyocardial hematoma mimicking abnormal left ventricular trabeculation

Intramyocardial hematoma may present as a tumor or pseudoaneurysm on echocardiography. A 68-year-old man was admitted with a subacute posterior wall infarction complicated by ventricular fibrillation. Echocardiography showed isolated left ventricular abnormal trabeculations, a finding suggesting an associated skeletal muscle disorder, in the lateral wall. At cardiac surgery, performed 6 weeks later because of severe 3-vessel disease, an intramyocardial hematoma of the lateral wall was excised, and myocardial and skeletal muscle biopsies were taken, which showed neither isolated left ventricular abnormal trabeculations nor skeletal muscle disorder. Postoperatively, echocardiography revealed no abnormal trabeculations.

Surgical treatment of a chest-wall penetrating left ventricular pseudoaneurysm

This report describes the treatment of a patient who developed a chest-wall penetrating pseudoaneurysm 3 years after coronary bypass grafting and after the resection of a lateral wall left ventricular aneurysm twice. The patient presented with a pulsatile tumor in the left submammilar region. Surgery was done in deep hypothermia, with femoro-femoral cannulation and via a left anterolateral thoracotomy. The perioperative course was uneventful and the patient is still well 5 years after surgery.

Severe mediastinal haemorrhage after a rugby tackle

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