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A 57 year-old man with a history of mitral valve replacement 12 years before was admitted
for prolonged palpitations and congestive heart failure. Electrocardiogram showed
sustained ventricular tachycardia. After cardioversion, despite the poor acoustic
window, echocardiography showed a huge left paraventricular chamber (6 cm length) with a large neck (5 cm width), involving the basal segments of the lateral, posterior and inferior walls,
associated with mitral prosthesis rocking (Fig. 1 and Video I). Left ventricle (LV) function was severely depressed. Cardiac magnetic
resonance confirmed the presence of a multilobar pseudoaneurysm (8 cm × 6 cm) with a wide neck (6.5 cm), involving the basal inferior and inferolateral segments, with pericardial late
enhancement (Fig. 2). Lateral insertion of the mitral prosthesis was supported only by the false aneurysm
(Video II). Cardiac computed tomography showed diffuse parietal calcifications in
the pseudoaneurysm as well as a large mural thrombus (Fig. 2). The patient was proposed for heart transplantation which occurred a few months
later (Fig. 2). Histological analysis of the explanted heart confirmed the diagnosis by revealing
the absence of myocardial cells in the wall of the chamber.
Figure 1(A–C) 2D echocardiography images showing the presence of a large left paraventricular
cavity (*) and its relation to basal segments of the posterior (A), lateral (B) and
inferior (C) wall, as well as its wide neck.
Figure 2(A) Magnetic resonance (MR) 4 chamber view showing the relation of the pseudoaneurysm
with the left ventricle and the mitral valve, as well as the sharp interruption of
the myocardial wall characteristic of pseudoaneurysm; (B) MR short axis view once
again showing the relative position of the cavity to the left ventricle and the apparent
absence of myocardial wall; (C) MR 2 chamber view revealing late gadolinium enhancement
in the pericardium (arrows); (D) computed tomography (CT) image showing the calcifications
in the wall of the pseudoaneurysms, suggestive of chronicity; (E) CT image showing
the presence of a thrombus inside the pseudoaneurysm (*) as well as the diffuse mural
calcification (arrows), both findings compatible with long term evolution; (F) explanted
heart, where the real dimensions of the pseudoaneurysm can be apreciated.
A case of left ventricular pseudoaneurysm with long survival and congestive heart failure as first presentation. Case report and review of the literature.
