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• W3205723828 abstract "TOPIC: Imaging TYPE: Medical Student/Resident Case Reports INTRODUCTION: Cardiac pseudoaneurysms is an uncommon sequelae of transmural myocardial infarctions. They have the potential to compromise the ventricular stroke volume and are a frequent source of thrombus formation due to stasis and swirling of blood in the area. We present a challenging case of a pseudoaneurysm with thrombus that anticoagulation was not pursued due to risk of wall rupture. CASE PRESENTATION: A 57-year-old male with a medical history of coronary artery disease status post percutaneous coronary intervention of the left circumflex artery presented for shortness of breath. On arrival, patient was tachycardic, normotensive and saturating above 95% on room air. Chest x-ray was performed which showed interstitial edema. Given concern for decompensated heart failure, a transthoracic echocardiogram was performed. This revealed an ejection fraction of 25% with left ventricular dilatation, concerning for an aneurysm and a hypoechoic area demonstrating a possible thrombus. With an unclear diagnosis, a cardiac magnetic resonance imaging(MRI) was pursued, which revealed a large inferolateral pseudoaneurysm with a mural thrombus. Upon appreciation of the thrombus, anticoagulation was highly considered. However, the thrombus was deemed to provide critical structural support to the atrophic segment of the pseudoaneurysm and anticoagulation was not pursued. Patient received IV diuretics and was discharged in stable condition. At six months follow up, the patient was in overall good clinical condition with repeat TTE demonstrating no significant changes. DISCUSSION: Most cases of pseudoaneurysms present as an uncommon sequela of transmural myocardial infarctions. They form as a contained rupture of the left ventricle by either pericardium or an organized thrombus. Pseudoaneurysms are known to have a poor prognosis given the high risk for rupture. If untreated, 30-45% of left ventricular pseudoaneurysms rupture in the first year. Due to the rarity of pseudoaneurysms, there are no randomized controlled trials that determine treatment choices. Most are medically managed with adequate blood pressure control and anticoagulation in those complicated by a thrombi. However, left ventricular thrombi are also known to endothelialize within the myocardium, decreasing its embolic potential. Theoretically, organized thrombi can provide stability between the myocardium and pericardium in the volatile area of a pseudoaneurysm. Disrupting this process with anticoagulation may place more pressure on the pericardium and can lead to wall rupture, which possesses a significantly high mortality rate. CONCLUSIONS: Avoiding anticoagulation should be considered in incidences of left ventricular thrombus with pseudoaneurysms. As evidenced by this case, this type of scenario warrants further investigation into the clinical outcomes of those who receive anticoagulation versus those who do not. REFERENCE #1: Bisoyi S, Dash AK, Nayak D, Sahoo S, Mohapatra R. Left ventricular pseudoaneurysm versus aneurysm a diagnosis dilemma. Ann Card Anaesth. 2016;19(1):169-172. doi:10.4103/0971-9784.173042 REFERENCE #2: Mathur M, Gupta S. Cardiac Pseudoaneurysm- A Death Defying Entity. J Clin Diagn Res. 2016;10(6):TD06-TD7. doi:10.7860/JCDR/2016/19956.7936 REFERENCE #3: Gatewood RP Jr, Nanda NC. Differentiation of left ventricular pseudoaneurysm from true aneurysm with two dimensional echocardiography. Am J Cardiol. 1980 Nov;46(5):869-78. doi: 10.1016/0002-9149(80)90442-7. PMID: 7435399. DISCLOSURES: No relevant relationships by Pooja Dhruva, source=Web Response No relevant relationships by Fadi Kandah, source=Web Response No relevant relationships by Naji Maaliki, source=Web Response No relevant relationships by Edin Sadic, source=Web Response no disclosure on file for Raj Shukla" @default.
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• W3205723828 date "2021-10-01" @default.
• W3205723828 modified "2023-09-25" @default.
• W3205723828 title "BETWEEN A CLOT AND A RUPTURE: A CHALLENGING DECISION" @default.
• W3205723828 doi "https://doi.org/10.1016/j.chest.2021.07.1356" @default.
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