ECHO 2013 / Acute Coronary Syndromes Echo in the Assessment of Complications

Diagnosing LV Pseudoaneurysm

MRI

–Absence of delayed enhancement of the myocardium with marked delayed enhancement of the

pericardium strongly suggestive of a false aneurysm

Konen B et al Radiology 2005;236:65-70

Varghese A et al. Heart 2005

66 yo male with CKD, HTN, hyperlipidemia, and ischemic cardiomyopathy (EF 15%), CAD s/p inferior MI (RCA occlusion) in 1992 complicated by VSD, s/p repair x 2

Diagnosis:

1. RV infarction with aneurysm of the inferior wall

2. Pericardial effusion

3. Pseudoaneurysm

4. Pericardial cyst

Saline Contrast Injection

Rotating to Apical 2Ch View

Other Diagnostic Tests

MRI

–Loss of epicardial fat at the orifice of pseudoaneurysm

–Absence of myocardium (difficult if myocardial layer very thin)

May distinguish thrombus from myocardium from pericardium

Frances C et al. JACC 1998;32:557-61

Natural History of Pseudoaneurysm

Natural history

– Rupture in 30-45%

of pts (with fatal outcome) even late after MI

– Early surgery

recommended for most patients

Chronic PA (> 3 months post MI) has lower risk of rupture however persistent risk of arrhythmia, embolic events.

–Surgical mortality rate: 7-23% (vs 48% medically)

– Long-term survival excellent

Harpaz D et al JASE 2001;14:219-27.

Frances C et al. JACC 1998;32:557-61

Definitions

True aneurysm:

–A wide-mouthed local bulge of the LV wall with a gradual transition from relatively normal myocardium to the thinner fibrous wall and an endocardial lining.

Pseudoaneurysm:

– A small-mouthed bulge resulting from a ruptured ventricular wall and thus its wall is composed of adhering pericardium and organized hematoma.

Subepicardial

–Relatively narrow neck formed by an abrupt interruption of the myocardial wall and its wall is composed of epicardium with or

without a thin myocardial layer

Hironaka, E et al. J Am Soc Echocardiogr 1997;10:192-96.