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CARDIOVASCULAR JOURNAL OF AFRICA • Volume 30, No 1, January/February 2019
AFRICA
e3
Discussion
LV pseudo-aneurysm is the result of myocardial rupture
contained by adherent pericardium or scar tissue, unlike a true
aneurysm, which involves the full thickness of the thin cardiac
wall.
1
The aetiology of pseudo-aneurysm is various, the most
common cause being transmural MI.
2
LV pseudo-aneurysm
may also be found after cardiac surgery, previous chest trauma,
infection or inflammation.
1,3-5
In a study of 290 patients with cardiac pseudo-aneurysm,
clinical presentation was characterised by congestive heart
failure (36%), chest pain (30%) and dyspnoea (25%). However,
over 10% of the aneurysms were asymptomatic and diagnosed
incidentally using various imaging tools.
2
Electrocardiogram and chest X-ray are not sensitive or
specific enough to diagnose LV pseudo-aneurysm. Multiple
diagnostic imaging modalities are useful in the differential
diagnosis. Echocardiography is usually the first imaging modality
to diagnose pseudo-aneurysm because of its wide availability,
non-invasiveness and rapid diagnosis.
Pseudo-aneurysm typically comprises a ratio of
<
0.5 between
the width of the neck and the maximal diameter of the
aneurysmal sac.
6
The presence of colour Doppler flow extending
from the left ventricle to the aneurysmal space through the
narrow neck is another important finding in LV pseudo-
aneurysm.
7
Recently, contrast echocardiography with to-and-fro
flow using a contrast microbubble was used to identify pseudo-
aneurysm. Cardiac CT is another useful non-invasive method
to detect three-dimensional structure, such as location, anatomy
of the aneurysm, myocardium, coronary arteries and bypass
grafts.
8
Recently, a LV coronary angiogram also identified a LV
pseudo-aneurysm with a narrow neck that communicated with
the left ventricle.
9
There are no guidelines for the management of pseudo-
aneurysm due to its rarity. However, early diagnosis and prompt
surgical repair is the treatment of choice because of a high risk
of spontaneous rupture, leading to a poor prognosis.
10
The pseudo-aneurysm in this case was identified four years after
post-infarction VSD patch closure. The patient was asymptomatic
and it was detected incidentally through regular follow-up
echocardiography. The delayed pseudo-aneurysm may have
occurred due to dehiscence of the patch in the friable myocardium,
leading to mechanical rupture of the repaired pericardium.
Conclusion
Because of the rarity of the condition, there are no long-term
data on delayed complications after post-infarction VSD closure.
However, from this case, we highlight the importance of long-
term follow up using multiple imaging modalities.
References
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Fig. 5.
Intra-operative photograph (surgeon’s view) reveals
the 1-cm-diameter perforation. The arrow indicates
the perforation, which was the point of communication
with the pseudo-aneurysm.