Ventricular pseudoaneurysm rupture – a potentially fatal complication of myocardial infarction

A 75-year-old hypertensive female patient presented at the cardiac department because of chest pain 20 days earlier. A suspicion of a past myocardial infarction (MI) and a pseudoaneurysm developed after echocardiography performed in the admissions office. Coronary angiography showed all vessels patent apart from the occluded left circumflex artery (LCx) (Figure 1 A). Echocardiography showed pseudoaneurysm of the lateral wall of the left ventricle (LV) and small pericardial effusion (Figure 1 B). Clinical status of the patient was stable. Cardiac magnetic resonance (CMR) was performed to rule out other cardiac pathologies – the free heart wall rupture was visualized, and consequently left ventricular pseudoaneurysm was confirmed (Figures 1 C, D). There were no abnormal laboratory results, and biomarkers of myocardial necrosis were negative. The patient was scheduled for urgent cardiac surgery. While waiting for cardiac surgery in the intensive care unit, sudden clinical state worsening was observed with symptoms of cardiogenic shock such as tachycardia (HR 120–130 bpm), blood pressure decrease (BP 65/40 mm Hg) and logic contact impaired. The following echocardiographic imaging showed heart tamponade (Figure 1 E). The patient was prepared for emergency surgery. EuroSCORE II was calculated as 21.75%. Surgery with arterial cannulation via femoral artery access to facilitate extracorporeal circulation was performed. The aneurysmal sac was cut to some degree over the right atrium to perform vein cannulation. In the next step tamponade was decompressed, showing ruptured pseudoaneurysmal sac size 51 × 39 × 31 mm (Figure 1 F). Cooley’s method was used to close the aneurysm. Clamp time was 39 min and whole extracorporeal circulation time was 79 min. The patient was discharged from hospital on the 12th day after surgery in a good clinical state.
Despite development of interventional cardiology and widespread use of endovascular procedures in treatment of acute coronary syndrome, there are still observed mechanical complications of myocardial infarction. Left ventricular pseudoaneurysm is a relatively rare complication that is reported in less than 0.1% of all MI patients and the main risk factors are older age, female sex, hypertension and inferior and lateral wall MI [1]. Pseudoaneurysm is formed when cardiac rupture is contained by adherent pericardium or scar tissue, in contrast to true aneurysm which comprises full thickness of the wall [1]. Around 40%...


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