Unusual rupture of left ventricular pseudo-false aneurysm secondary to subacute anterolateral myocardial infarction: a case report
Left ventricular (LV) pseudo-false aneurysm is a rare complication secondary to myocardial infarction and is caused by intramyocardial dissecting hematoma due to fragile myocardium. Very occasionally, intramyocardial dissecting hematoma appears as a neocavitation entirely contained within the myocardial wall (so called “pseudo-false LV”) and is an unusual form of subacute cardiac rupture.
A 38-year-old male experienced chest discomfort 3 weeks ago, which improved within few days. However, after that episode, he presented at our hospital with rapidly deteriorating severe breathlessness in a preshock state with acute heart failure. Emergency coronary angiography revealed an occluded left anterior descending artery. An intra-aortic balloon catheter was inserted because of unstable hemodynamics. Enhanced computed tomography revealed extensive aneurysm formation in the LV anterior wall and contrast leakage from the inner cavity to the LV myocardium, with a moderately accumulated pericardial effusion. Emergency surgery revealed a large aneurysmal sac on the anterior wall, slightly attached to the pericardium. A 5-mm, slit-like, oozing-type, rupture site was detected in the LV after dissecting the pericardium.
To our knowledge, this is the first report of a pseudo-false aneurysm on the LV anterior wall. Subacute rupture of pseudo-false LV aneurysm is rare.
KeywordsLeft ventricular pseudo-false aneurysm Subacute cardiac rupture Intramyocardial dissecting hematoma
Intra-aortic balloon pumping
Left anterior descending artery
A cardiac free wall rupture following acute myocardial infarction is a rare and fatal condition. Frequently, an intramyocardial dissecting hematoma may appear as a neocavitation entirely within the myocardial wall . This unusual form of subacute cardiac rupture is termed “left ventricular (LV) pseudo-false aneurysm” and is characterized by the development of dissection planes between the spiral muscles of the ventricle . We report an uncommon case of ruptured LV pseudo-false aneurysm following subacute anterior myocardial infarction.
Discussion and conclusions
In 1981, Stewart et al.  reported the first case of an LV pseudo-false aneurysm, which is a rare complication secondary to myocardial infarction. Although this condition is caused by intramyocardial dissecting hematoma due to fragile myocardium, the hematoma does not dissect completely through to the epicardium contained within the infarct myocardial area as opposed to a pseudoaneurysm. The differential diagnosis between pseudoaneurysm and pseudo-false aneurysm is definitively reached through pathophysiological examination. In the present case, the pathological findings of the LV wall containing the myocardial tissue were consistent with those of a pseudo-false aneurysm, which is contained by the elements of the ventricular wall. Also, intramyocardial hematoma was considered to suddenly develop in the subacute phase of anterior myocardial infarction . Fortunately, bleeding from the ruptured dissecting myocardium was minimally controlled because of slight attachment to the epicardium.
In the majority of reported cases, pseudo-false aneurysms develop in the posterior or inferior wall . Otherwise, rupture to right ventricular is also more common [6, 7]. However, a pseudo-false aneurysm occurring in the anterior wall, as observed in the present case, are extremely rare and has not been reported previously to our knowledge. Anatomically, this may be attributed to the crossing of two ventricular myocardial bands at the anterior wall, producing two helicoid spirals .
The choice of repair for a ventricular aneurysm depends on the condition of the myocardium. In the acute or subacute phase, the LV defect was closed using a bovine pericardial patch and transmural interrupted mattress sutures because of the fragile myocardium. In addition, Teflon pledgets were used to reinforce the suture on the outside. Subsequently, the ventricular edge was closed with interrupted and running sutures using Teflon felt strips.
To our knowledge, this is the first report of an LV anterior wall pseudo-false aneurysm. Subacute rupture of pseudo-false LV aneurysm is rare.
The authors would like to thank Enago (www.enago.jp) for the English language review.
Availability of data and materials
Data sharing was not applicable to this article as no datasets were generated or analyzed during the study.
MO, HW, KS, YF, and KM participated in the discussion regarding the pathophysiology and drafted the manuscript. MO and KM critically reviewed the manuscript. All authors read and approved the final version of the manuscript.
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The patient consented to the publication of this case report.
The authors declare that they have no competing interests.
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