Left Ventricular Pseudoaneurysm in an Adult with a Repaired Incomplete Atrioventricular Canal
Presented By:
Kathryn Wershing, DO; Joseb Colon; Jorge Alegria, MD; Joseph Paolillo, MD; Matthew Schwartz, MD
Atrium Health Levine Children's Hospital
kathryn.wershing@atriumhealth.orgOverview:
Introduction: Rarely, myocardial infarction can lead to a left ventricular pseudoaneurysm. Rupture of the pseudoaneurysm is associated with significant mortality and, as a result, surgical resection is the preferred treatment strategy. However, some patients are poor surgical candidates and medical management alone is sometimes necessary. Only limited reports exist that describe longterm survival in patients managed without surgical resection.
Case Description: A 39-year-old male with trisomy 21 and history of an incomplete atrioventricular canal (AVC) defect repaired at 26 years old presented with an embolic stroke. He was treated with transcatheter thrombectomy and thrombolytics. Imaging demonstrated a large pseudoaneurysm (9 x 6cm) involving the lateral left ventricle with thrombus and small proximal left circumflex artery that appeared occluded entering the atrioventricular groove. He likely suffered left circumflex injury during the AVC repair with resultant myocardial infarction. Surgical resection was risky given the defect’s broad base. The patient was managed with anticoagulation and has been stable without further events 3 years later.
Discussion: A pseudoaneurysm is an uncommon complication of myocardial infarction and results from rupture of the left ventricular wall. We suspect that our patient had a left circumflex artery injury and subsequent myocardial infarction following previous AVC defect repair. Surgical resection is preferred as it lowers the risk of spontaneous rupture and possible death. However, surgical resection is not always feasible as was the case with our patient. Limited reports of survival after medical therapy alone exist. Frances et al. reported 31 patients with post-infarction left ventricular pseudoaneurysms that were medically treated and 48% died at median follow up of 1 week. Of the surviving patients, 5 patients were reported alive at > 5 yrs from diagnosis (1). Zhong et al. reviewed 17 cases of post myocardial infarction left ventricular pseudoaneurysms. The overall survival was higher amongst the surgical group compared to the medically managed group (100% vs. 57%, p=0.02) (2). To lower the risk of repeat neurologic event, we anticoagulated our patient with apixaban. Although he remains at risk for pseudoaneurysm rupture and embolic event, he is doing well at 3 years from diagnosis.
Conclusion: The development of a left ventricular pseudoaneurysms is a rare, but life-threatening consequence of myocardial infarction. Surgical repair is the preferred management given their risk of rupture. We described a 39-year-old male with suspected myocardial infarction following congenital heart defect repair who developed large ventricular pseudoaneurysm who was a poor surgical candidate due to the broad base of the defect. He was managed with anticoagulation alone and is stable at 3 year follow-up.
Case Description: A 39-year-old male with trisomy 21 and history of an incomplete atrioventricular canal (AVC) defect repaired at 26 years old presented with an embolic stroke. He was treated with transcatheter thrombectomy and thrombolytics. Imaging demonstrated a large pseudoaneurysm (9 x 6cm) involving the lateral left ventricle with thrombus and small proximal left circumflex artery that appeared occluded entering the atrioventricular groove. He likely suffered left circumflex injury during the AVC repair with resultant myocardial infarction. Surgical resection was risky given the defect’s broad base. The patient was managed with anticoagulation and has been stable without further events 3 years later.
Discussion: A pseudoaneurysm is an uncommon complication of myocardial infarction and results from rupture of the left ventricular wall. We suspect that our patient had a left circumflex artery injury and subsequent myocardial infarction following previous AVC defect repair. Surgical resection is preferred as it lowers the risk of spontaneous rupture and possible death. However, surgical resection is not always feasible as was the case with our patient. Limited reports of survival after medical therapy alone exist. Frances et al. reported 31 patients with post-infarction left ventricular pseudoaneurysms that were medically treated and 48% died at median follow up of 1 week. Of the surviving patients, 5 patients were reported alive at > 5 yrs from diagnosis (1). Zhong et al. reviewed 17 cases of post myocardial infarction left ventricular pseudoaneurysms. The overall survival was higher amongst the surgical group compared to the medically managed group (100% vs. 57%, p=0.02) (2). To lower the risk of repeat neurologic event, we anticoagulated our patient with apixaban. Although he remains at risk for pseudoaneurysm rupture and embolic event, he is doing well at 3 years from diagnosis.
Conclusion: The development of a left ventricular pseudoaneurysms is a rare, but life-threatening consequence of myocardial infarction. Surgical repair is the preferred management given their risk of rupture. We described a 39-year-old male with suspected myocardial infarction following congenital heart defect repair who developed large ventricular pseudoaneurysm who was a poor surgical candidate due to the broad base of the defect. He was managed with anticoagulation alone and is stable at 3 year follow-up.
