Heart Views

CASE REPORT
Year
: 2016  |  Volume : 17  |  Issue : 4  |  Page : 154--158

Abnormal color flow signal traversing the myocardial wall: Not everything is what it appears to be


Kathy Edelman1, Angel López-Candales2,  
1 Division of Cardiovascular Medicine, University of Pittsburgh Cardiovascular Institute, Pittsburgh, PA, USA
2 Division of Cardiovascular Medicine, School of Medicine, University of Puerto Rico, San Juan, Puerto Rico, USA

Correspondence Address:
Dr. Angel López-Candales
Division of Cardiovascular Medicine, School of Medicine, University of Puerto Rico, Medical Sciences Building, PO Box 365067, San Juan, Puerto Rico 00936-5067
USA

Abstract

A case of a patient presenting with an acute myocardial infarction is presented. A transthoracic echocardiographic examination revealed an abnormal color flow signal that traversed the myocardial wall from a large inferior aneurysm and initially considered to be a ventricular septal defect. However, further echocardiographic manipulation utilizing modified views along with sequential injections of both agitated saline and Definity® proved very useful to identify a pseudoaneurysm. There was no further need for any other diagnostic test, and the patient was treated surgically, undergoing successful repair of the pseudoaneurysm as well as coronary artery bypass grafting of the left coronary artery.



How to cite this article:
Edelman K, López-Candales A. Abnormal color flow signal traversing the myocardial wall: Not everything is what it appears to be.Heart Views 2016;17:154-158


How to cite this URL:
Edelman K, López-Candales A. Abnormal color flow signal traversing the myocardial wall: Not everything is what it appears to be. Heart Views [serial online] 2016 [cited 2019 Oct 18 ];17:154-158
Available from: http://www.heartviews.org/text.asp?2016/17/4/154/201782


Full Text

 Introduction



Identification of a myocardial pseudoaneurysm has a high morbidity and mortality and this case how special manipulation of the echocardiographic transducer not only identified the presence of an abnormal color Doppler signal, but also prompted the use of agitated saline and contrast injections to confirm the presence of a pseudoaneurysm. This intervention was sufficient to identify the diagnosis and ultimately direct definitive therapy.

 Case Report



We report a case of a 61-year-old Caucasian female who presents to a community hospital with chest pain, shortness of breath, and electrocardiographic changes suggestive of an acute inferior myocardial infarction. Upon arrival to our institution, cardiac catheterization was emergently performed in view of the persistent ST-segment elevations in the inferior leads II, III, and aVF with elevation in serum troponin levels and showed extensive disease of a dominant right coronary artery (RCA) with an 80–90% lesion in the midsegment followed by a long 60–70% more distal stenosis as well as a proximal 70% lesion of the left anterior descending artery. Right heart hemodynamics showed evidence of right ventricular infarction and multiple Taxus stents were used to treat the lesions within the RCA.

A transthoracic echocardiogram was then performed in the Intensive Care Unit for evaluation of left ventricular function showing an inferior wall aneurysm with overall preserved systolic function. Three days later, another transthoracic echocardiogram was performed for a new murmur, which showed an abnormal color flow signal suggestive of a ventricular septal defect in the short axis view as seen in [Figure 1]. From the apical 4-chamber view, a cystic structure was seen lateral to the right ventricular wall [Figure 2]. Inferior angulation of the transducer from the 4-chamber view, as seen in [Figure 3], shows a long neck of the pseudoaneurysm connecting the inferior aneurysm to the cystic structure with color Doppler confirming blood flow within this structure.{Figure 1}{Figure 2}{Figure 3}

Injection of agitated saline failed to opacify the cystic structure [Figure 4]. However, opacification of this cystic structure occurred after the intravenous administration of Definity ® [Figure 5]. Furthermore, a better definition of the contained rupture that compressed the basal right ventricular free wall was obtained with this maneuver [Figure 6]. Otherwise, left ventricular size and systolic function remained as previously described.{Figure 4}{Figure 5}{Figure 6}

 Discussion



A pseudoaneurysm, or false aneurysm, develops after an acute myocardial infarction, which is complicated by a ventricular free wall rupture that is contained by localized pericardial adhesions.[1] The diagnosis needs to be established early since these aneurysms are prone to rupture.[2]

In the most extensive review of the literature, Frances et al. reported that 253 patients with a pseudoaneurysm in whom the cause was reported, 55% were related to an inferior wall myocardial infarction, as reported in our case.[3] In this review, the authors also reported that the second most common cause of pseudoaneurysm formation was surgery, which was responsible for 33% of cases followed by trauma that accounted for 7% of cases.

The site of pseudoaneurysm varies with etiology and in a review of 52 patients seen at the Mayo Clinic pseudoaneurysms were primarily seen in the inferior or posterolateral wall after a myocardial infarction, in the right ventricular outflow tract after congenital heart surgery, in the posterior subannular region of the mitral valve after mitral valve replacement, and in the subaortic region after aortic valve replacement.[4]

The most frequent symptoms associated with left ventricular pseudoaneurysm were chest pain and dyspnea.[3] Sudden cardiac death was the presenting manifestation in about 3%, whereas 12% of patients were asymptomatic.

The most reliable method for diagnosis of a pseudoaneurysm has been angiography, which demonstrates a narrow orifice leading to a saccular aneurysm and lack of surrounding coronary arteries.[5] Left ventricular angiography has resulted in a definitive diagnosis in over 85% of patients.[3] Transthoracic echocardiography has been considered a reasonable first step, but definitive diagnosis of pseudoaneurysm has only been reported in up 26% of patients.[6]

This case report presents this very unusual case showing how an abnormal color flow signal that traverses a myocardial wall is not always a ventricular septal defect. As described above, further echocardiographic manipulation utilizing modified views along with sequential injections of both agitated saline and Definity ® proved very useful to identify the correct pathologic process and by itself was sufficient to provide definitive therapy. There was no further need for any other diagnostic test, and the patient was treated surgically, undergoing successful repair of the pseudoaneurysm as well as coronary artery bypass grafting of the left coronary artery.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

References

1Dachman AH, Spindola-Franco H, Solomon N. Left ventricular pseudoaneurysm. Its recognition and significance. JAMA 1981;246:1951-3.
2Vlodaver Z, Coe JI, Edwards JE. True and false left ventricular aneurysms. Propensity for the altter to rupture. Circulation 1975;51:567-72.
3Frances C, Romero A, Grady D. Left ventricular pseudoaneurysm. J Am Coll Cardiol 1998;32:557-61.
4Yeo TC, Malouf JF, Oh JK, Seward JB. Clinical profile and outcome in 52 patients with cardiac pseudoaneurysm. Ann Intern Med 1998;128:299-305.
5al-Saadon K, Walley VM, Green M, Beanlands DS. Angiographic diagnosis of true and false LV aneurysms after inferior wall myocardial infarction. Cathet Cardiovasc Diagn 1995;35:266-9.
6Kupari M, Verkkala K, Maamies T, Härtel G. Value of combined cross sectional and Doppler echocardiography in the detection of left ventricular pseudoaneurysm after mitral valve replacement. Br Heart J 1987;58:52-6.