Cardiac pseudoaneurysms: a clinical case series

Abstract

Background: Cardiac pseudoaneurysms are a potentially life-threatening pathology with a variety of non-specific clinical manifestations. This case series uniquely shares a collection of rare pathologies with differing preceding risk factors and presentations, with an emphasis on the utility of multi-modality imaging in diagnosis and management.

Case summary: We present three cases of cardiac pseudoaneurysms. Case 1 is a 27-year-old woman with delayed presentation of a traumatic left ventricular pseudoaneurysm (LVP). Case 2 is a 73-year-old man with post-myocardial infarction LVP. Case 3 is a 38-year-old man with left ventricular outflow tract pseudoaneurysm after aortic valve replacement.

Discussion: Cardiac pseudoaneurysms are rare and important to diagnose in a timely manner. Advances in non-invasive imaging modalities have improved our ability to distinguish pseudoaneurysms from other pathologies, leading to more timely management.

Keywords: Cardiac magnetic resonance; Cardiac pseudoaneurysm; Case report; Multi-modality imaging.

Figure 1

Transthoracic echocardiogram parasternal long-axis view in systole (A) and diastole (B) revealed a 3.8 × 6.8 cm thickening in the lateral wall of the left ventricle concerning for infiltrative process vs. tumour, indicated by the star. Apical four-chamber view demonstrates this, in systole (C) and diastole (D), indicated by the arrow. Cardiac magnetic resonance imaging was done on a Siemens Aera 1.5T scanner. Cine sequences were done using steady-state free precession sequences with 0.6 mm slice thickness and 0.4 mm gap. Delayed enhancement sequences were done using high TI imaging with a TI of 600 ms for thrombus evaluation and low TI imaging with a TI of 320 ms, adjusted to the null time, for delayed enhancement and scar imaging. Four-chamber view cine (E) shows large left ventricular basal inferolateral pseudoaneurysm, adjacent to the mitral valve, measuring 3.3 cm at the mouth, 4 cm in depth, and 5.9 at the largest dimension, with dense material filling the pseudoaneurysm, suggestive of thrombus (star). Four-chamber perfusion imaging (F) showing normal myocardial perfusion and lack of perfusion of the dense material in the pseudoaneurysm, suggestive of a thrombus (star). Short-axis high TI imaging (G), with an inversion time of 600 ms, with dark appearance of the dense material in the pseudoaneurysm, consistent with a thrombus (star). Four-chamber delayed enhancement imaging (H) showing inferolateral pseudoaneurysm filled with thrombus (star), covered by overlying pericardium.

Figure 2

Cardiac magnetic resonance imaging. Pseudoaneurysm in each image is denoted by an arrow. Four-chamber view cine in systole (A) and diastole (B), with reduced function, measured LVEF of 33% and apical septal pseudoaneurysm. High TI imaging (C) with dark appearance of the dense material in the pseudoaneurysm, consistent with a thrombus. Delayed enhancement imaging (D) shows pseudoaneurysm containing thrombus at the apex of the left ventricle. The pseudoaneurysm measures 4.4 × 2.8 cm.

Figure 3

Cardiac computed tomographic angiography imaging. Pseudoaneurysm (arrow) can be seen on the medial aspect of the left ventricular outflow tract body measuring 4.4 cm × 2.2 cm (A). The stars indicate the openings to the pseudoaneurysm. The patient’s bioprosthetic aortic valve can be seen just superior to the pseudoaneurysm. Additional views include CCTA showing two openings into the pseudoaneurysm and the corresponding orthogonal plane through each opening into the pseudoaneurysm (B), with ascending aorta (circle) above this, and left ventricular outflow tract (square) below.