Successful management of a delayed-presented and complicated right ventricular pseudoaneurysm: a case report and literature review

Abstract

Introduction: Right ventricle (RV) pseudoaneurysm is a substantially rare but fatal condition that should be diagnosed promptly to prevent severe complications, such as rupture and death. However, due to its nonspecific presentation, its diagnosis relies mainly on advanced imaging cardiac modalities. This report describes the successful management of a delayed and unusual presentation of RV pseudoaneurysm.

Case presentation: A 31-year-old white male patient with a history of pericardiectomy presented with chest pain and dyspnea, which worsened by exertion, and edema of the lower extremities, which had started several weeks ago and had been exacerbated over time. The initial evaluations with cardiac enzyme check, chest X-ray, and electrocardiogram were unremarkable, and the patient was planned to undergo a transthoracic echocardiogram (TTE). TTE revealed RV failure and increased RV diameter; a suspicious lesion in the RV apex was also detected, suggesting a pseudoaneurysm. Cardiac Computed Tomography (CTA) confirmed the diagnosis, and interventional treatment via an Amplatzer device was considered, which was rejected by the interventional cardiologist of the center due to the lack of experience and logistics for such intervention. Considering the patient's condition deterioration, the patient was transferred to an operating room, and an open-heart surgery was performed to suture the ruptured RV myocardium. The pericardial effusion was removed. The histopathological evaluation of the sample confirmed the diagnosis. The post-surgical recovery and follow-up were uneventful. The graphical abstract is added below to illustrate the case and summarize it.

Conclusion (clinical key point): Right ventricle pseudoaneurysms can present with unusual symptoms and signs, and misdiagnosis is highly probable. Advanced imaging techniques after the initial echocardiogram might be necessary to confirm the diagnosis. Moreover, timely, appropriate, and wisely chosen treatment (interventional or surgical) can result in uneventful treatment and recovery.

Keywords: Cardiac imaging; Cardiac surgery; Case report; Echocardiography; Pseudoaneurysm; Right ventricle.

Fig. 1

An echo-free space located apical to the right ventricular apex in a modified right ventricular apex view

Fig. 2

A. An outpouching sac located apical to the right ventricle is depicted using an off-axis view during systole, with the arrow indicating the narrow neck between the sac and RV (expanded in systole). B. Another outpouching sac is shown apical to the right ventricle using an off-axis view in diastole (contracted)

Fig. 3

The Color Doppler study reveals communication between the right ventricle and the outpouching. (A) During the diastolic phase, blue indicates blood returning to the RV. (B) In the systolic phase, red signifies blood moving to the outpouching due to RV contraction

Fig. 4

An axial image at the level of the right ventricle (RV) apex was obtained during cardiac CT angiography. The scans revealed a contrast-filled outpouching, which features a well-defined margin and a thin wall (indicated by the red arrow). This outpouching is connected to the apical portion of the RV through a narrow neck (shown by the yellow arrow). Additionally, there was no evidence of thrombosis or calcification within the sac

Fig. 5

Right ventricular (RV) inflow view obtained using X-plane imaging, providing a perpendicular assessment of the RV apex and inflow tract. Postoperative imaging reveals an intact RV apex and preserved structural integrity throughout the RV, with no evidence of residual pseudoaneurysm or wall defect

Fig. 6

Off-axis apical four-chamber view optimized to visualize the right ventricular apex following surgical repair of a right ventricular pseudoaneurysm. The image demonstrates an intact right ventricular free wall with no residual outpouching or defect, consistent with successful closure and restoration of normal right ventricular anatomy