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\begin{document}

\title{Giant Left Ventricular Apical Pseudoaneurysm}



\author[1]{Krishna Prasad Gourav}%
\author[1]{JAVID RAJA}%
\author[1]{SUNDER NEGI}%
\author[1]{Revanth Maramreddy}%
\affil[1]{Post Graduate Institute of Medical Education and Research}%


\vspace{-1em}



  
  \date{May 23, 2024}


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\begin{abstract}
Left ventricular free wall rupture (LVFWR) can occur after myocardial
infarction. Sometimes LVFWR can be contained by a pericardium leading to
the formation of the pseudoaneurysm. In view of the high tendency to
expand and rupture an urgent surgery is indicated. We experienced a rare
case of giant left ventricular apical pseudoaneurysm which was
successfully managed with surgical intervention.%
\end{abstract}%



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\textbf{Case}

A 47-year-old male patient came to our hospital with an acute onset of
chest pain and was diagnosed with anterior wall myocardial infarction
(MI) which was managed conservatively. Four weeks later he came to his
physician with a complaint of heaviness in chest since 12 hrs.
Transthoracic echocardiogram (TTE) revealed a large 12x10cm
pseudoaneurysm located at the left ventricular (LV) apex that
communicated with the pericardial cavity through a 24mm defect (Figure
1; Video 1). Flow across the defect was confirmed by color flow Doppler
(Figure 2; Video 2). Coronary angiography revealed complete occlusion of
the left anterior descending artery. Emergency surgery was planned in
view of massive LV pseudoaneurysm. After the induction of anesthesia, a
median sternotomy was done. A large LV apical pseudoaneurysm was
visualized which was contained by a thick, densely adherent fibrous
capsule of the pericardium. The Cardiopulmonary bypass (CPB) was
initiated after systemic heparinization. After aortic cross-clamp, a
complete dissection of the heart was performed, to avoid systemic
embolization. Antegrade cold blood cardioplegia was delivered to arrest
the heart. The aneurysm sac was opened by a longitudinal incision
(Figure 3). The defect was located close to the apex of the LV, which
was closed with a Gore-Tex patch to avoid possible distortion of the
heart structures. Bioglue was applied over it and the patient was taken
off bypass. The CPB was terminated with ionotropic support of milrinone
0.4mcg/kg/min and noradrenaline of 0.05mcg/kg/min. The patient was
successfully shifted to the intensive care unit with stable hemodynamics
and the trachea was extubated after 24 hours. A written informed consent
was taken from the patient and the case was approved by the
institutional review board.

\textbf{Discussion:}

The left ventricular free wall rupture (LVFWR) after MI decreased
drastically in the current era due to the advancement of effective early
revascularization strategies. Sudden cardiac death is a common sequel of
LVFWR, however, in some cases, it can be contained by the superimposing
adherent pericardium resulting in the formation of the pseudoaneurysm.
The pseudoaneurysm communicates with the LV cavity by a narrow neck,
whose diameter is less than 50\% of the maximum internal dimensions of
an aneurysm.\textsuperscript{1} Whereas, LV true aneurysm develops due
to scar thinning of the myocardial wall after MI. It contains all the
three layers of LV i.e endocardium, myocardium, and epicardium, and has
a wide neck, smooth margins. The posterolateral wall is the most common
location for LV pseudoaneurysm , whereas, a true aneurysm, located
commonly in the apicoanterior wall. TTE is used as an initial diagnostic
modality for the assessment of heart after MI. It not only helps in
diagnosis, but also helps in determining the location and extent of the
lesion. Due to its high tendency to expand and rupture, early surgical
intervention is recommended in LV pseudoaneurysm. Our case had developed
a giant LV psudoaneurysm four weeks after the development of MI which
was successfully managed by the surgical intervention.

Reference :

Eren E, Bozbuga N, Toker ME, et al. Surgical treatment of
post-infarction left ventricular pseudoaneurysm: a two-decade
experience. Tex Heart Inst J 2007;34:47--51.

Legends :

Figure 1 - Apical four chamber view showing an apical pseudoaneurysm
(red arrow) with narrow neck (green arrow). RA,Right atrium; RV, Right
ventricle; LA, Left ventricle; LV, Left ventricle.

Figure 2 - Colour Doppler in apical four chamber view showing a free
blood flow between left ventricular cavity and pseudoaneurysm (red
arrow). RA,Right atrium; RV, Right ventricle; LA, Left ventricle; LV,
Left ventricle.

Figure 3 -- Surgical image showing a ruptured left ventricular apex
(green arrow).

Video 1 : Apical four chamber view showing an apical pseudoaneurysm with
narrow neck.

Video 2 : Colour Doppler in apical four chamber view showing a free
blood flow between left ventricular cavity and pseudoaneurysm.\selectlanguage{english}
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\includegraphics[width=0.70\columnwidth]{figures/Figure-1/Figure-1}

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\includegraphics[width=0.70\columnwidth]{figures/Figure-2/Figure-2}

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\includegraphics[width=0.70\columnwidth]{figures/Figure-3/Figure-3}

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