Echo Singapore 2009

LV
Aneurysms
How to image?
What numbers matter ?
Does Remodelling Surgery
Help ?
J.C. Mohan
New Delhi
India

LV aneurysm is
defined as a discrete
thin-walled dyskinetic
or akinetic segment of
the chamber with a
variable sized
communication to the
LV cavity

McMahon CJ, Moniotte S, Powell AJ, del Nido PJ, Geva T. Usefulness of magnetic
resonance imaging evaluation of congenital left ventricular aneurysms. Am J
Cardiol. 2007; 100: 310–315

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 Case #1: 45M symptomatic (HF)
chest pain occurred 2 months back following stress

LV
RV PE
LA

Sharp Discontinuity

2
Pseudo-aneurysm with chronic Cardiac
Rupture
Aneurysm

LV

PE

Pleural Effusion

Operated in April 2008

Dor’s Procedure

25/5/2009
26/3/2008

3
Case #2:40-yr male. AMI on Dec 10 , 2009

June 2, 2009
January 14 , 2009

6month Follow-up on Ace-I/BB/Eplerinone

Wide-necked Pseudoaneurysm

4
 Case#3: 64-yr male with old inferior
MI and class II Dyspnoea

Post-op
Pre-op
Sept 12, 2009
April 28, 2005

Pseudoaneurysm • True aneurysm

Cardiac Localised
rupture Outpouched and
contained dyskinetic
by adherent thinned out
pericardium myocardium
or scar having all the 3
tissue layers

True LV Aneurysm

Injured or infarcted myocardium displays greater

plasticity or creep, defined as deformation or stretch over
time under a constant load

5
 Pseudo-aneurysm: Following
inferoposterior MI

True or False
• True aneurysm, which occurs in 5%–10%
of patients with AMI , does not tend to
rupture at the chronic stage and therefore,
in the absence of other indications for
surgery (eg, refractory angina pectoris,
congestive heart failure, systemic
embolization, or refractory arrhythmia) is
treated medically
• False aneurysm usually is treated
surgically Pseudoaneurysm is more
frequent than recognised

• True Left ventricular aneurysms occur

with the long-term form of infarct
expansion

• cardiac rupture is an extreme form of

acute infarct expansion which may result
in pseudoaneurysm subsequently

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 Pseudo-pseudoaneurysm
Cardiac rupture
contained by
outer or
subepicardial
muscular layer

No visible Communication with LV Cavity

Subepicardial Aneurysm:Visible
communication of ruptured tract

Post-MI Pseudo-pseudo
Aneurysm

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 Imaging Modalities
• Echo
• MRI
• Cath Angio
• CT Angio
• Radionuclide studies
• positron-emission tomography (PET) can be
helpful early after infarction to differentiate true
aneurysm from hibernating myocardium with
reversible dysfunction

True Aneurysm
• Ischemic
• Congenital
• HCM
• Infective ( Chaga’s Disease)
• Sarcoidosis
• Trauma
• Flow Jet Lesions
• After Apical Venting or CMV

• Of 1299 HCM
patients, 28 (2%)
were identified with
left ventricular apical
aneurysms, including
a pair of identical
twins Maron et al
Sept 22, 2008
Circulation

Prognostically significant

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 True Apical Aneurysm in HCM
• left ventricular apex
has to be considered
a locus minoris
resistentiae due to the
thinner helical
architecture of
myocardium in the
apical loop

Post-infarct vs HCM
• Cardiac MRI : apical LV aneurysm is
associated with myocardial
hyperenhancement and a lower ejection
fraction and that apical LV thinning is a
common finding in HCM with asymmetrical
septal hypertrophy and it does not show
delayed enhancement

65-yr female with normal CAG

LV

Congenital True Aneurysm

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 5-year post-MVR
33-yr male

Pseudoaneurysm: Etiology
• IHD(MI) 55%
• Post-surgery 33%
• Trauma 7%
• Infections 5%
• Congenital ( inter-
annular
discontinuity )
JACC 1998
Frances C et al
True natural history remains ill-
defined with 30-45% rupture rates

Pseudoaneurysms
• More often inferoposterior/lateral
• Narrow Neck ( orifice
diameter/internal diameter of
aneurysm 0.25-0.5 vs 0.9-1.0)
• Turbulent to-and-fro flow
• Stagnation/SEC/thrombi
• Sudden loss of myocardial int egrity
• Sharp discontinuity of endocardium
• Pseudoaneurysm expands in
Systole
Pericardial hyperenhancement

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 TB Pseudo-aneurysm
Presenting as HF

Wide-necked Pseudo-aneurysm

LV

LA

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Wide-necked False Aneurysms
• Only 4% on
diaphragmatic/posteri
or region are true
• Wide Neck is possible
• Endocardium/myocar
dial cells present in
wall in true aneurysm

Post-MVR: Submitral
Pseudoaneurysm

Bantu’s Aneurysm or Congenital

Subannular aneurysm

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 25-yr male with HF: PAN

Bantu’s Submitral Aneurysm

Pseudoaneurysms
• 75% have non-specific ST-T changes on
ECG

Symptomatic 88%
HF Asymptomatic
Chest pain 12%
Dyspnoea
SCD

Frances C et al: JACC 1998;32:557

N=290 ( literature review)

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 Differential Diagnosis

Diverticulum True LV aneurysm

1. Contractile outpouching 1. Non-contractile
2. Narrow neck 2. Broad-neck
3. Full thickness healthy 3. Scar and Q wave on ECG’s
muscular wall
4. Altered LV geometry
4 No alteration in rest 5. Coronary involvement
of LV geometry 6. Usually with MR
5. Associations

Echo and CE-MRI are the best

imaging modalities
• Contrast ventriculography was diagnostic
in 54% of patients in whom it was
performed, as opposed to 97% for two-
dimensional echocardiography (p = 0.2).

Fernando A ,Surgical Tt of L V Pseudo-aneurysms

ATS , Feb 2007
N=30
Pericardial enhancement is invariable in false aneurysm but is also
present in 15 % of true aneurysms
Konen E, Merchant N, Gutierrez C, et al: True versus false left ventricular aneurysm:
Differentiation with MR imaging—Initial experience. Radiology 2005; 236:65

Contrast Cath-based Angiography tends to miss basal

pseudo-aneurysms and submitral aneurysms and may
dislodge thrombi

LAO View :

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• Intense delayed
enhancement of the
pericardium is noted
in all cases of false
aneurysm

Sensitivity 100%
Specificity 84%

Contrast-enhanced MRI for

Thrombi and True vs False
Aneurysm
• Mollet et al ( Circ 2002):
TTE 9% vs MRI 21%
• German study : TTE
14% vs 41% ( ROFO
2005)

Ventricular Reconstructive Surgery

vs Prognosis

Attractive Hypothesis
with limited data

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 Asymptomatic
Symptomatic

Grondin et al, Circ 2005

Surgical Ventricular Reconstruction

CAD+ anteroapical dysynergy+ EF <35%

0%
-2%
-4%
-6% Similar
-8% NYHA class
LVESV -10% Mortality
-12% Hospitalisation
P<0.001
-14%
-16%
-18%
-20%
CABG CABG+SVR

STICH: Jones RH et al: ACC 2009

Surgery for Remodelled LV

• Most psuedoaneurysms and pseudo-
pseudoaneurysms need surgery
• All symptomatic True aneurysms need
surgery
• Asymptomatic true aneurysms may be
left alone even when associated with CAD
• Post-valve replacement small false
aneurysms can be followed medically

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 Summary ( ctd)
• the risk of thromboembolism is low for patients
with aneurysms (0.35% per patient-year), and
long-term anticoagulation is not usually
recommended
• However, in the 50% of patients with mural
thrombus visible by echocardiography after MI,
19% develop thromboembolism over a mean
follow-up of 24 months
• Reconstructive surgery reduces volumes but
does not improve prognosis

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