What is the summary of left ventricular pseudoaneurysms?

From the Guidelines

Left ventricular pseudoaneurysms are a life-threatening complication of myocardial infarction, characterized by contained rupture and tamponade, with high mortality rates approaching 60%.

Characteristics and Risk Factors

• They are observed most frequently in patients with first MI, anterior infarction, the elderly, and women 1.
• Other risk factors include hypertension during the acute phase of STEMI, lack of antecedent angina or prior MI, absence of collateral blood flow, Q waves on ECG, use of corticosteroids or nonsteroidal anti-inflammatory drugs, and administration of fibrinolytic therapy >14 hours after symptom onset 1.

Diagnosis and Management

• Pseudoaneurysm formation can be recognized with transthoracic echocardiography 1.
• Emergency surgery should be considered in patients with pseudoaneurysm formation and contained rupture 1.
• The management of left ventricular aneurysms, which can be related to pseudoaneurysms, involves surgical ventricular reconstruction (SVR) or left ventricular aneurysmectomy during coronary artery bypass grafting (CABG) in selected patients 1.
• However, the evidence provided does not directly address the management of left ventricular pseudoaneurysms, and the treatment approach may vary depending on individual patient factors and institutional protocols.

From the Research

Definition and Causes of Left Ventricular Pseudoaneurysms

• Left ventricular pseudoaneurysm is a rare disease defined as a ventricular rupture contained by epicardium, pericardial adhesions, or both 2, 3.
• It most frequently occurs as a complication of acute myocardial infarction 2, 4, 5.
• Other causes include cardiac surgery and chest trauma 3.

Clinical Characteristics and Symptoms

• The symptoms of left ventricular pseudoaneurysms are nonspecific and may include chest pain, dyspnea, and syncope 5.
• Some patients may be asymptomatic 3.
• Common presenting symptoms also include congestive heart failure 3.

Diagnosis and Treatment

• Diagnosis is often delayed due to nonspecific symptoms and requires diagnostic imaging modalities such as echocardiography and computed tomography angiogram 5.
• Surgical treatment is recommended for pseudoaneurysms that are large or symptomatic and for those discovered less than 3 months after myocardial infarction 2, 4.
• Urgent surgery is the treatment of choice for left ventricular pseudoaneurysms occurring within 3 months from acute myocardial infarction, especially if larger than 3 cm in diameter 4.
• Percutaneous closure of the cavity has been described as an alternative treatment option for patients with anterior left ventricular pseudoaneurysm and a well-defined fibrotic neck, who are deemed at excessively high surgical risk 4.

Outcomes and Prognosis

• Left ventricular pseudoaneurysms are associated with a high risk of rupture and high mortality rate, especially if left untreated 4, 3.
• Surgical mortality rate remains significant, with a rate of more than 20% 4.
• Prompt diagnosis and early surgical intervention are essential for patients with large or expanding left ventricular pseudoaneurysms due to the high propensity of fatal rupture 6.
• Associated coronary artery bypass grafting may reduce early mortality of patients with left ventricular pseudoaneurysm by resuscitating the ischemic myocardium 6.