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INTRODUCTION:
Pseudoaneurysm of the left ventricle (LV) usually develops following ventricular rupture due to transmural myocardial infarction (MI) (1). The incidence of LV free wall rupture following MI is 2% (2). Free wall rupture causes fatal pericardial tamponade in most cases, but in some, the thrombus becomes organized within the limitation of the surrounding tissues and pericardium, and becomes a cavity that results in pseudoaneurysm formation(3).
CLINICAL REPORT:
A 48 years old man, a chronic smoker, had an acute anterior and inferior wall myocardial infarction two years back. No thrombolytic therapy was done due to late presentation. Echo done at that time revealed a large dyskinetic area involving anteroapical, posteroapical and apical septal portion of myocardium with no other abnormality. He now presented  with progressively worsening dyspnoea on exertion since the last one week and left hypochondrial pain and palpitations for the last 3 to 4 days. ECG and Cardiac enzymes were not elevated. A transthoracic echo was done which revealed a moderately enlarged left ventricular cavity with a large pseudoaneurysm involving distal septum and apex and a large apical thrombus. A thin fluttering membrane was seen covering the thrombus. In the short axis of the LV distal to the papillary muscle, this membrane appeared to be detached from other layers except from 1 to 5 O  clock position. A layer of blood with spontaneous echo contrast was seen between this fluttering endocardium and the LV clot. No communication of this blood cavity with the left ventricular cavity could be clearly demonstrated. The LV ejection fraction was about 40 %. There was a small collection of pericardial fluid near RV apex close to the aneurysm. A cardiac MRI with contrast confirmed the echocardiographic findings (Fig 1).  In addition, transmural infarcts were noticed in territories of the left anterior descending branch and the right coronary artery branch. A preoperative coronary angiogram showed single vessel disease with occlusion of the distal LAD. The patient was taken for an urgent pseudoaneurysm repair.
The approach was through a standard median sternotomy with exposure and cannulation of the femoral vessels prior to sternotomy. Manipulation of the heart was avoided prior to cardiopulmonary bypass to prevent rupture or embolization.  The pericardium was found to contain about 50 ml of serosanguinous fluid. There were no adhesions in the pericardium. The anteroapical and the inferoapical  portion of LV was hugely aneurysmal. The epicardium overlying the aneurysmal portion of LV was intact, but it was thin and bulging, with fresh clots visible underneath. Upon incising the epicardium, these clots were evacuated. In addition, a large, organized clot was found in the dilated portion of the left ventricle close to the apex. The aneurysmal portion of the LV was excised till healthy tissue (Fig 2). An encirclage suture was taken through the healthy LV tissue. A circular goretex patch measuring about 4 cm in diameter was used to repair the defect using 2-0 Prolene continuous sutures. The LV wall was approximated over the goretex patch with continous 2-0 prolene. Subsequent revascularization of left anterior descending and diagonal branches was done. Postoperatively, the patient was electively ventilated for twenty four hours, IABP was inserted to ensure adequate hemodynamics which was discontinued after 72 hours. The patient remained in the intensive care unit for four days and was discharged on the tenth postoperative day. Echo done postoperatively showed moderate LV dysfunction with an ejection fraction of 35- 40%. At 3 months postop, the patient is in NYHA class II.
DISCUSSION: 
Left ventricular pseudoaneurysm is a serious complication of transmural myocardial infarction. Being a rare condition, the natural history of LV pseudoaneurysm is unknown. They are usually localized to the inferobasal and posterobasal segments of the LV. In our case, the pseudoaneurysm involved the apex and extending to the anteroapical and inferoapical portions of the LV. Pseudoaneurysms do not have a definite symptomatology. They most commonly present with heart failure symptoms, chest pain and dyspnoea, but they are asymptomatic in 10% of the cases. Currently, echocardiography (transthoracic or transesophageal) is the diagnostic standard (4) for diagnosis of pseudoaneurysms as it has the ability to visualize the heart in different planes and distinguish the myocardium from other structures. Characteristic echocardiographic findings suggestive of a false aneurysm include a sharp discontinuity of endocardial image at the site of pseudoaneurysm communication with the left ventricular cavity, a saccular or globular contour of the false aneurysmal chamber and the presence of a relatively narrow orifice compared with the diameter of the aneurysm fundus (5). Two other characteristics of pseudoaneurysm include systolic expansion of the aneurysmal cavity and displacement of other cardiac chambers. At times, visualization of the myocardial wall at the pseudoaneurysm site is difficult and one cannot distinguish a pseudoaneurysm from a localized pericardial effusion, hematoma, pericardial cyst or diverticulum. In these cases, colour flow imaging facilitates diagnosis by demonstrating shunting of blood from the left ventricular cavity into the aneurysm and back. Pulsed doppler demonstrating turbulent flow at the neck of a cavity or the cavity itself also suggests a pseudoaneurysm (6). In our case, preoperative diagnosis was established by echocardiography. Although, it did not fit into the classic definition of a pseudoanurysm according to the echocardiographic criteria, the fact that it was a psudoaneurysm was based on its location and the absence of myocardium in the aneurysmal cavity. No communication between the aneurysmal cavity and the left ventricle was demonstrable on echo, but the presence of an endocardium which was detached from all the other layers and was seen fluttering depending upon the dynamic left ventricular  pressure changes  suggested a communication. A diagnosis of intramural hematoma or myocardial dissection was not ruled out. However, in those cases, the position of the endocardial membrane would have been the same regardless of the left ventricular pressure changes. This fluttering endocardium is a unique finding and has not been reported in literature. The only other unique finding reported in literature has been the presence of an echo free space behind the left atrium communicating with the left ventricular cavity (7,8).
 Intraoperatively, there was no evidence of either a hematoma or a dissection. Even the detached endocardiium could not be demonstrated in the arrested heart when the pseudoaneurysm was excised. It is possible that this endocardium got excised while excising the cavity.

Surgery is indicated for all patients as soon as the diagnosis is established, unless the surgical risk is prohibitive (7), especially for large or expanding pseudoaneurysms, regardless of symptoms. This approach is justified by uncertain natural history in regard to rupture and risk of embolizing thrombotic material.

REFERENCES:
Eren E, Bozbuga N, Toker ME, Keles C, Rabus MB, Yildirim O, et al. Surgical treatment of post-infarction left ventricular pseudoaneurysm: a two-decade experience. Tex Heart Inst J 2007;34:47 51.
Moreno R, Lopez de Sa E, Lopez-Sendon JL, Garcia E, Soriano J, Abeytua M, et al. Frequency of left ventricular free-wall rupture in patients with acute myocardial infarction treated with primary angioplasty. Am J Cardiol 2000;85:757 60, A8.

Malcolm ID, Fitchett DH, Stewart D, Marpole D, Symes J. Ventricular aneurysm: false or true? An important distinction. Ann Thorac Surg 1980;29:474 7.

Sutherland GR, Smyllie JH, Roelandt JR. Advantages of colour flow imaging in the diagnosis of left ventricular pseudoaneurysm. Br Heart J 1989;61:59 64.

Catherwood E, Mintz GS, Kotler MN, Parry WR, Segal BL. Two-dimensional echocardiographic recognition of left ventricular pseudoaneurysm. Circulation 1980; 62: 294-303.

Loperfido F, Pennestri F, Mazzari M, Biasucci LM, Vigna C, Laurenzi F. Diagnosis of left ventricular pseudoaneurysm by pulsed Doppler echocardiography. Am Heart J 1985; 110:1291-3.

Sidebotham D, Lai J. An abnormal echo free space behind the left atrium. Journal of Cardiothoracic and vascular anaesthesia 2004; 18: 671-72.

Weston MW, McKinnon E, Donald T, Vijaynagar R, Canedo M. Clin. Cardiol 1991; 14: 526-28.
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