ONE
NUMBER
CALL

Reason for Transfer

• 84M visiting from UK, daughter pancreatic Ca
• 5 days of on and off chest pain
• 2 days ago severe chest pain for hours, then resolved, Tn+, ECG not STEMI criteria as per Kitchener - recommended med management
• Yesterday worsening chest pain, SOB, hypotensive 50-60 systolic -->norepinepherine
• Decision to transfer for angiography given concern for cardiogenic shock

PMH

• CABG x 3 2000, England
• Prostate Ca - remote
• PMR
• GERD
• ?Wedge resection for Lung Ca

Social

• Former smoker

MEDS

1. ASA
2. Atorvastatin
3. Bisoprolol
4. Plavix
5. Enoxaparin
6. Ramipril (held)
7. Norepi - 11mcg/hr
8. Lansoprazole
9. Prednisone
10. Ceftrixone

Initial LHSC ECG

Day 2

Day 3

LEFT
HEART
CATH

RAO

15

Caudal

8

LAO

20

Caudal

2

RAO

13

Caudal

6

RAO

12

Cranial

21

LAO 3

Caudal 15

RAO 10

Cranial 6

LAO 4

Caudal 1

RAO 12

Cranial 16

LAO 22

Caudal 1

Coronary Arteries:

• LM: 50%
• LAD: 100% prox, filled by LITA
• Cx: 95% prox-mid
• RCA: 100% origin

Bypass:

• LITA-LAD: patent
• SVG-RCA: lucency above native RCA ?occluded on aortogram (?culprit)

Cath Report

ECHO

CARDIO
GRAPHY

Echo Report

• Mildly dilated left ventricle with mild to moderately impaired systolic function
• Anterior, basal to mid anterolateral and inferolateral walls are hypokinetic
• Mod MR, Mild AR, Mild-Mod AS
• Large basal inferior aneurysm. Appearances suggest a true ventricular aneurysm rather than a pseudoaneurysm
• No thrombus is present within it
• Appears to be communication with a vessel in the atrioventricular groove, possibly a coronary-cameral fistula involving the left circumflex artery
• No pericardial effusion

BP SOFT EFFUSION ON POCUS

Repeat Echo

• Small pericardial effusion
• No extravasation of contrast demonstrated

DIFF

ERENTIAL DIAGNOSIS

Free Wall Rupture

• Acutely lethal that it is rarely imaged 
• Sudden new pericardial effusion in a patient with marked thinning and akinesis at the terminal myocardial territory of the occluded artery 
• Echocardiographic features of tamponade are usually present.
• Pericardial effusion may contain spontaneous echocardiographic contrast or organized clot
• Demonstration of low-velocity colour Doppler flow or extravasation of intravenous echocardiographic contrast from the LV cavity into the effusion would confirm wall rupture

Free Wall Rupture

Youtube: @Kannan D

Youtube: @Irfan _18IZ

Ventricular Aneurysm

• "Well delineated, thin, scarred, or fibrotic wall, devoid of muscle or containing necrotic muscle, that is a result of a healed transmural myocardial infarction (MI)"
• Incidence: 8-15% of Q wave MI (predominantly anterior)
• Develops in the first 3 months post MI and can be apparent by hospital discharge

Uptodate

Ventricular Aneurysm

Uptodate

Pseudoaneurysm (PsA)

• Ventricular free wall perforation that is locally contained by adjacent pericardium and adhesions.
• Definitive feature  is disruption of all three layers: endocardium, myocardium, and epicardium
• More often after inferior MI, although they may arise in the lateral and apical regions.
• Appear as echo-free spaces or extra chambers adjacent to and continuous with the LV cavity...distinguishing traits such as a narrower neck with more ragged edges and turbulent bidirectional flow

Pseudoaneurysm

Braunwald

Wikipedia

COMPUTED TOMO

GRAPHY

LA

LV

PsA

CT Report

• Evidence of myocardial rupture involving the LV basal and inferior wall segments with formation of large complex pseudoaneurysm with multi lobulated components.
• No evidence of thrombus
• No clear CT evidence of active contrast extravasation from the pseudoaneurysm
• LITA-LAD and SVH-PDA graft appear patent

What
Should
We do?

Pseudoaneurysm (PsA)

• Uncommon complication of MI. Incidence 0.23% in a series of 2600 patients. Diagnosis variable from few days to months
• Untreated pseudoaneurysms have a 30 to 45 percent risk of rupture and, with medical therapy, a mortality of almost 50 percent
• Surgery is the preferred therapeutic option. With current techniques, the perioperative mortality is less than 10 percent
• Prolonged survival has been observed even in a few patients who do not undergo surgery

 https://www.ncbi.nlm.nih.gov/pubmed?term=1132088

https://www.ncbi.nlm.nih.gov/pubmed?term=9741493

Surgical Options

1. Primary closure with sutures

2. Patch closure (either dacron patch or autologous pericardial patch)

3. Combination patch plus suture closure

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5369265/

Case Courtesy of Dr. Chu

• 52M, Lateral Stemi, IABP, BMS to CX, Discharged

Transcatheter Closure

• Varying access: transvenous, transpical
• Insertion of occluder device

Dudiy 2011: Percutaneous Closure of Left Ventricular Pseudoaneurysm

https://www.ahajournals.org/doi/pdf/10.1161/CIRCINTERVENTIONS.111.962464

Tang 2018: Transcatheter Closure of Complex Post-Myocardial Infarction Left Ventricular Pseudoaneurysm and Unique Post-Traumatic Right Ventricular Pseudoaneurysm

https://www-jstage-jst-go-jp.proxy1.lib.uwo.ca/article/ihj/60/4/60_18-577/_pdf/-char/en