Ilídio Jesus

Manuel P Magalhães

Pedro Cordeiro

Pedro Sousa

Rui Ferrinha

Salomé Pereira

Sousa, Pedro

Victor Brandão

Walter Santos

Springer

Pseudoaneurysm inside of a true aneurysm

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Sousa et al. Journal of Cardiothoracic Surgery 2013, 8:97
http://www.cardiothoracicsurgery.org/content/8/1/97CASE REPORT Open AccessPseudoaneurysm inside of a true aneurysm
Pedro Sousa1*, Walter Santos1, Pedro Cordeiro1, Salomé Pereira1, Rui Ferrinha1, Victor Brandão1,
Manuel P Magalhães2 and Ilídio Jesus1Abstract
Left ventricular pseudoaneurysms and true aneurysms are two possible complications of myocardial infarction.
However, while pseudoaneuryms require urgent surgical resection, true aneuryms can often be managed medically,
making imperative an accurate diagnosis.
The authors describe a case of a delayed rupture of a true aneurysm that was contained and gave rise to a
pseudoaneurysm inside of a true aneurysm. The echocardiography allowed the differential diagnosis for a timely
surgical intervention which resulted in the patient’s full recovery.
Keywords: Pseudoaneurym, True aneurysm, EchocardiographyBackground
Left ventricular (LV) aneurysms are a possible conse-
quence of extensive myocardial necrosis that occurs more
often as a result of an anterior MI.
Rupture of the LV free wall is a rare but catastrophic
complication of an acute MI [1]. Rarely, rupture is
contained by the overlying pericardium resulting in a
pseudoaneurysm [1,2]. The diagnosis of LV pseudoa-
neurysm can be challenging, because patients are often
asymptomatic or present nonspecific symptoms [1-3].
For this reason, pseudoaneurysm is frequently an inci-
dental finding on imaging tests [1,4].
While pseudoaneurysms require urgent surgical resec-
tion because of the likehood of rupture, true aneurysms
can often be managed medically. This difference makes
imperative an accurate diagnosis [1,2,4].
Echocardiography proves to be valuable in this diffe-
rential diagnosis. An echocardiographic series reported
that in pseudoaneurysms the ratio of the maximum
diameter of the neck to the maximum internal diameter
of the cavity was between 0.25 and 0.50 [1,3]. Conver-
sely, this ratio is > 0.50 in true LV aneurysms. Pseudoa-
neurysms are also more often located in the posterior or
inferior wall [1,3,4]. One possible explanation is that
rupture of the anterior wall usually results in immediate
death, in contrast with rupture of the posterior wall [1].* Correspondence: Peter_senado2002@yahoo.com
1Cardiology Department, Faro Hospital, Faro, Portugal
Full list of author information is available at the end of the article
© 2013 Sousa et al.; licensee BioMed Central L
Commons Attribution License (http://creativec
reproduction in any medium, provided the orThe authors describe a case of a delayed rupture of a
true aneurysm that was contained by the pericardium,
which prevented the patient death and gave rise to a
pseudoaneurysm inside of a true aneurysm. Echocardi-
ography made the diagnosis which was later confirmed
by the surgical report.Case presentation
We report a case of a 57-year-old man, caucasian, with a
history of hypertension, dyslipidemia and former smo-
king, that suffered 13 years ago an acute antero-lateral
myocardial infarction (MI) and was then submitted to
angioplasty with stents implantation in the left anterior
descending (LAD) and circumflex arteries. In the follow-
up he was informed that he had developed a left ven-
tricular (LV) aneurysm.
He remained asymptomatic until 2 years ago, when
he was brought to the Emergency Department with a
syncopal episode. The ECG on admission revealed the
presence of sinus rhythm with Q waves, ST segment ele-
vation and negative T waves in the anterior and lateral
leads, which were findings that were already known for
previous ECG after MI. The biomarkers of myocardial
necrosis were elevated with a peak troponin I of 3,2 μg/L.
He was then admitted to the Cardiology Department with
the diagnosis of non-ST segment elevation acute MI.
The transthoracic echocardiography (Figure 1) revealed
a moderate LV systolic dysfunction with hypokinesia of
the anterior and inferior walls and septum and an apical
LV aneurysm. Surprisingly, the apical aneurysm contourtd. This is an Open Access article distributed under the terms of the Creative
ommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and
iginal work is properly cited.
Figure 1 Transthoracic echocardiogram revealing the pseudoaneurysm with a large thrombus inside. A- Four chamber view
(1-aneurysm neck; 2-aneurysm maximum diameter; 3- pseudoaneurysm neck; 4- pseudoaneurysm maximum diameter), B- Parasternal short axis
view at apical level (1- pseudoaneurysm maximum diameter; 2 and 3- pseudoaneurysm neck) C- Two chambers view in systole with the
maximum diameter of the neck [2] and the maximum internal diameter of the pseudoaneurysm [3]. D- Four chamber view using contrast
(1-aneurysm neck; 2- aneurysm maximum diameter; 3- pseudoaneurysm neck).
Sousa et al. Journal of Cardiothoracic Surgery 2013, 8:97 Page 2 of 4
http://www.cardiothoracicsurgery.org/content/8/1/97exhibited an abrupt discontinuity that gave access to an-
other cavity filled with an echodense material. The rela-
tionship between the maximum diameter of the neck and
the maximum internal diameter of this cavity was inferior
to 0.5, suggesting that this cavity was a pseudoaneurysm
with a large thrombus inside.
3-D echocardiography showed calcification of the peri-
cardium and echo-contrast filling out the pseudoaneu-
rysm neck (Figure 2).
The coronary angiography revealed a sub-occlusive
stenosis of the stent in the LAD and the left ventri-
culography demonstrated an apical aneurysm surroun-
ded by another giant apical cavity suggestive of a
pseudoaneurysm that seemed to be carpeted by a
thrombus (Figure 3).
Patient underwent coronary artery bypass surgery and
resection of the pseudoaneurysm –externally the apex
region was fully adherent to the pericardium with areasof calcification on the “wall” making the dissection
impossible in this area. A circular incision was made
around the perimeter of the apex and it was evident
in this cutting zone that there was no muscle tissue
and that the residual wall was formed by thickened
pericardium and organized thrombus.
One year after the surgery, the patient remained
asymptomatic and without any image suggestive of
pseudoaneurysm in the apical region of the left ven-
tricle (Figure 4).
Conclusions
This clinical case is interesting in several aspects. First, it
reports a delayed rupture of a true aneurysm that pro-
bably occurred 11 years after the aneurysm formation.
This is a very rare event, because the potential for rup-
ture of a true aneurysm is higher in the 2–3 weeks after
an acute MI.
Figure 2 3-D echocardiography with constrast, revealing calcification of the pericardium (arrows) and echo-contrast filling the
pseudoaneurysm neck (*).
Sousa et al. Journal of Cardiothoracic Surgery 2013, 8:97 Page 3 of 4
http://www.cardiothoracicsurgery.org/content/8/1/97Second, this is a rare case of a rupture of a true
aneurysm that was contained by the thrombus formation
and the pericardial adherences secondary to the previous
MI. This is an impressive event because it prevented the
patient death and gave rise to a pseudoaneurysm inside
of a true aneurysm. This pseudoaneurysm is conse-
quently located in the apical region, unlike the major-
ity of cases of pseudoaneurysms. Impressive images of
this rare echocardiographic finding are provided in
this case report.Figure 3 Left ventriculography revealed a pseudoaneurysm
with a thrombus.Finally, it highlights the importance of standard, con-
trast and 3-D echocardiography not only for the detec-
tion of LV pseudoaneurysms, but also for its differential
diagnosis. Because pseudoaneurysms have a high prob-
ability of rupture and death, not only during the early
stages of its development but also during the established
fibrous stage [5], the patient was quickly sent to surgery
with no time to perform MRI. The preoperative diagno-
sis of the pseudoaneurysm was then essentially based onFigure 4 Constrast echocardiography performed one year after
surgery showed a preserved LV systolic function, without
evidence of a pseudoaneurysm.
Sousa et al. Journal of Cardiothoracic Surgery 2013, 8:97 Page 4 of 4
http://www.cardiothoracicsurgery.org/content/8/1/97echocardiography and the definitive diagnosis was only
finally established by the surgical report.
Consent
Written informed consent was obtained from the patient
for publication of this case report and any accompanying
images. A copy of the written consent is available for re-
view by the Editor-in-Chief of this journal.
Abbreviations
LV: Left ventricular; MI: Myocardial infarction; LAD: Left anterior descending;
ECG: Electrocardiogram.
Competing interests
The authors declare that they have no competing interests.
Authors’ contribution
MPM performed the surgery and was responsible for the surgical discussion.
PC and RF evaluated the echocardiographic images. VB performed the
coronary angiography and the left ventriculography. WS, SP and IJ were
major contributors in writing the manuscript. All authors read and approved
the final manuscript.
Author details
1Cardiology Department, Faro Hospital, Faro, Portugal. 2Cardiothoracic
Surgery Department, Cruz Vermelha Portuguesa Hospital, Lisbon, Portugal.
Received: 16 July 2012 Accepted: 8 April 2013
Published: 17 April 2013
References
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Cardiol 1998, 32:557–561.
3. Tuan J, Kaivani F, Fewins H: Left ventricular pseudoaneurysm. Eur J
Echocardiogr 2008, 9:107–109.
4. Stehlik J, Maholic R, Thaman R: Massive left ventricular aneurysm.
Circulation 2004, 109:e203–e204.
5. Chao H, Lu M, Hung C: Spontaneous rupture of a left ventricular true
aneurysm. Ann Thorac Surg 2005, 80:1106–1108.
doi:10.1186/1749-8090-8-97
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Pseudoaneurysm inside of a true aneurysm

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