"Mushroom cloud": a giant left ventricular pseudoaneurysm after a myocardial infarction due to myocardial bridging--a case report

Abstract

Left ventricular pseudoaneurysm is an uncommon complication after transmural myocardial infarction, occurring when a free wall rupture is contained by adhesions of the overlying pericardium preventing acute tamponade. In this report, an unusual case of a 61 year-old male with a giant apical left ventricular pseudoaneurysm after an unnoticed myocardial infarction is presented. On coronary angiogram myocardial bridging of the distal left anterior descending artery was judged to be the infarct related lesion. The echocardiographic diagnosis allowed for a timely surgical intervention which resulted in the patient's full recovery.

Figure 1

Twelve-lead ECG at the time of re-admission. Note ST segment elevation (1.5 mm) in leads I, II, III, AVL, AVF, V3–V6 and T wave inversion from V3 to V6 and in AVL. Note the absence of Q waves.

Figure 2

Transthoracic echocardiography of the apical pseudoaneurysm. Four-chamber view demonstrates a large discontinuity of the ventricular wall in the apex, with the image resembling a "mushroom cloud".

Figure 3

Continuous-wave Doppler of flow across the neck of the pseudoaneurysm. Bidirectional turbulent flow into the pseudoaneurysm in systole and away from the pseudoaneurysm, into the left ventricular cavity, in diastole.

Figure 4

Demonstration of myocardial bridging. Significant luminal narrowing of the distal segment of the left anterior descending artery during systole (A) and relief during diastole (B).

Figure 5

Coronary angiography of left coronary artery. Myocardial bridging of the left anterior descending artery during systole (A). Absence of constriction during diastole (B).

Figure 6

Intraoperative view of the opened pseudoaneurysm.