Recurrent left ventricular pseudoaneurysm: diagnosed by color-flow Doppler echocardiography.

Abstract

The effects of left ventricular pseudoaneurysm following transmural myocardial infarction can be devastating; therefore, prompt diagnosis and surgical resection are warranted. We report a rare case of recurrent left ventricular pseudoaneurysm in which color-flow Doppler echocardiography was useful in establishing the diagnosis.

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Diagnostic
Technique
Carlos M. Gaos, MD
Sayid Fighali, MD
Ramiro Coronado, MD
Guillermo Hernandez, MD
Mario Quintanilla, MD
Denton A. Cooley, MD
Recurrent Left Ventricular
Pseudoaneurysm
Diagnosed by Color-Flow Doppler Echocardiography
The effects of left ventricular pseudoaneurysm following transmural myocardial infarc-
tion can be devastating; therefore, promptdiagnosis andsurgicalresection are warranted.
We report a rare case of recurrent left ventricular pseudoaneurysm in which color-flow
Dopplerechocardiographywas usefulin establishing thediagnosis. (TexasHeartinstitute
Journal 1990;17:190-1)
L
eft ventricular pseudoaneurysm is a rare but lethal complication oftransmu-
ral myocardial infarction. Because left ventricular pseudoaneurysms have a
tendency to rupture spontaneously,' surgical intervention is recommended
upon detection. We report a case of recurrent left ventricular pseudoaneurysm in
which color-flow Doppler echocardiography was used to establish the diagnosis.
Case History
Key words: Blood flow
velocity; echocardiography;
echocardiography, Doppler;
heart aneurysm; heart
ventricle; pseudoaneurysm
From: The Department
ofAdultCardiology, Texas
Heart Institute at St. Luke's
Episcopal Hospital, Houston,
Texas
Address for reprints:
Carlos M. Gaos, MD,
cdo Leachman Cardiology
Associates, 6720 Bertner,
Suite 2502, Houston,
7X 77030
In 1984, a 44-year-old man sustained a posterior myocardial infarction with left
ventricular wall rupture and left ventricular pseudoaneurysm formation, which
were successfully repaired. Three years later, the pseudoaneurysm recurred ad-
jacent to the site of prior surgery; again, surgical resection was undertaken, and a
woven Dacron patch was used for the repair. After the 2nd operation, the patient
was free of symptoms until 3 weeks before his next hospital admission (October
1988), when he developed progressive dyspnea on exertion, followed by parox-
ysmal nocturnal dyspnea and chest pain. A left ventricular angiogram revealed a
pseudoaneurysm, but the orifice between the 2 cavities (left ventricular and false
aneurysm) was not clearly seen. A coronary arteriogram disclosed 100% obstruc-
tion of the distal circumnflex artery and the 2nd obtuse marginal branch. Two-
dimensional echocardiograms revealed a 5- x 6-cm posterolateral echo-free space
and a 2.8-cm echocardiographic dropout in the posterolateral wall of the left
ventricle in the apical 4-chamber view (Fig. 1); these findings were suggestive of
pseudoaneurysm. Pulsed and color-flow Doppler showed systolic and diastolic
flow through the site of communication (Fig. 2). The patient again underwent sur-
gery, and a large pseudoaneurysm was found in the posterolateral wall adjacent to
the site of the previous surgery. We performed surgical resection and repair of the
pseudoaneurysm with a woven Dacron patch. The patient tolerated the procedure
well and was discharged.
Discussion
Pseudoaneurysm of the left ventricle, which follows a ventricular wall rupture, is
a localized hematoma surrounded by the parietal pericardial layer. The hematoma
(pericardial sac) expands with time, producing a "false" ventricular cavity. To our
knowledge, recurrence of left ventricular pseudoaneurysm has been reported only
once, in a patient with mural endocarditis.2 Of the 13 patients who underwent
surgery for left ventricular pseudoaneurysms during a 14-year period at the Texas
Heart Institute, only the patient reported herein experienced pseudoaneurysmal
recurrence.
For many years, cardiac angiography was the standard method ofevaluating left
ventricular pseudoaneurysm; however, during the last decade, noninvasive tech-
niques such as radionuclide imaging, ultrasonography, andcomputedtomography
190
Pseudoaneurysm Detected by Color-Flow Doppler Echocardiography
Volume 17,Number3, 1990

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Fig. 1 Two-dimensional echocardiogram of4-chamber apical
view Echo-free space indicating the pseudoaneurysm is seen
behind the left inferior wall; echo dropout is seen in the left
posterior wall (orifice or neck).
LV = left ventricle; LA = left atrium; PN = pseudoaneurysm
Fig. 2 Color-flow Doppler of4-chamber apical view and
pulsed Doppler Turbulent systolic flow is seen from the left
ventricle to the pseudoaneurysm.
LV = left ventricle; LA = left atrium; PN = pseudoaneurysm
have been valuable tools in the diagnosis as well.
Two-dimensional echocardiography has been rec-
ognized as an important technique in detecting left
ventricular pseudoaneurysms.3 In echocardiograph-
ic imaging, false-positive and false-negative results
are encountered primarily in the presence of echo-
cardiographic dropout, echo-free space images (as in
pericardial cyst), loculated pericardial or pleural effu-
sions, or ventricular diverticulum. Pulsed Doppler
studies, whereby flow velocities are measured, can
help detect the turbulent flow between false and
ventricular cavities. One limitation ofpulsed Doppler
has been the lack of visualization of the communi-
cation between the left ventricle and the false cham-
ber due to a poor acoustical window, an inadequate
echo-beam angle, or a narrow orifice.
Several reports have been published regarding
the usefulness of color-flow Doppler echocardiog-
raphy in the evaluation of left ventricular pseudo-
aneurysm.4-7 In color Doppler, flow signals, which are
superimposed on a 2-dimensional echocardiogram,
can be seen readily. In a case of left ventricular pseu-
doaneurysm, turbulent flow can be detected between
the left ventricle and the false chamber. In our patient,
the 2-dimensional echocardiogram showed dropout
in the left ventricular posterolateral wall with an
echo-free space image behind it, which was very sug-
gestive ofpseudoaneurysm. ColorDopplerdisplayed
a "mosaic" pattern within the pseudoaneurysm dur-
ing systole and diastole; this established the diagno-
sis, which was later confirmed by pulsed Doppler
and surgery.
Our experience illustrates several advantages of
color Doppler in the evaluation of left ventricular
pseudoaneurysms. Through a simple, noninvasive
method, the pseudoaneurysm's site of origin can be
detected. Color-flow Doppler is useful in caseswhere-
in the opening between the chambers is too small to
be seen with 2-dimensional echocardiography. Color
Doppler assists the diagnostician in distinguishing
between echo drop-out or echo-free space images
and leftventricular pseudoaneurysm. It is also helpful
in the follow-up of patients who might tend to devel-
op left ventricular pseudoaneurysms, such as those
who have undergone aneurysmectomy.
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