Encapsulated pseudoaneurysm post-left ventricular rupture: unusual presentation and follow-up (QF_SA_110)

Description of Clinical Presentation: We present a case of a 59-year-old woman with a history of heavy smoking and hypertension but no significant cardiovascular history. Her symptoms began 20 days earlier with chest pain, dyspnea, and fever, initially suspected to be community-acquired pneumonia, leading to empirical antibiotic treatment. Due to persistent symptoms, she visited a hospital where an electrocardiogram reveled elevated suspicions of an infarct. A transthoracic echocardiogram revealed a severely depressed ejection fraction with apical akinesia and an apical thrombus. These findings suggested an evolved acute myocardial infarction with apical aneurysm versus pseudoaneurysm, and she was referred to our hospital for further evaluation.

Diagnostic Techniques and Their Most Important Findings: At admission, she was hemodynamically stable with no signs of low cardiac output or heart failure. Coronary angiography revealed an occlusion in the mid-portion of the anterior descending artery with TIMI 0 flow, without collateral development. The remaining coronary arteries did not show other lesions. Subsequently, cardiac magnetic resonance imaging and cardiac computed tomography were performed and demonstrated severe left ventricular dysfunction, subacute myocardial infarction in the anterior descending artery territory, and a free wall rupture of the left ventricle with an apical pseudoaneurysm containing an associated sessile thrombus, which exhibited partial fragmentation in the strict apical region.
Considering the possibility of surgical intervention, pulmonary imaging revealed severe emphysema, and pulmonary function tests showed drastic obstructive ventilatory impairment. An interdisciplinary discussion was held, exploring the options of surgical repair or cardiac transplantation. For surgical repair with a patch, Dor procedure, the remaining volumes were deemed insufficient. Furthermore, cardiac transplantation in a patient with severe chronic obstructive pulmonary disease was both risky and likely futile. Therefore, in a joint decision with the patient, optimal medical treatment was established. Nine months after the diagnosis, the patient is still alive and asymptomatic.

Learning Points from this Case: The rupture of the left ventricular free wall is typically a catastrophic complication of myocardial infarction. Rupture usually happens 3 to 5 days after the infarction and often presents with cardiac tamponade and shock, with a very high mortality rate, even with urgent surgical intervention. However, some patients with subacute or contained rupture present a therapeutic window. The diagnosis of cardiac rupture, usually made with transthoracic echocardiography, is an indication for emergency surgery. In certain cases, a multi-imaging strategy with cardiac MRI and/or CT can complement the diagnosis and provide optimal anatomical characterization for surgical intervention.
While a benign form of presentation has been described in the literature, this is not common, and most patients die before reaching a hospital. Due to the patient’s benign presentation, a complete evaluation was possible, allowing the analysis of the anatomical and tissue characteristics of the ventricle via CT and cardiac MRI. With all the data available, in the risk-benefit equation, any type of intervention would likely cause more harm than good.