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Case 9

History

  • 80 yr old
  • Abnormal CXR
  • 8/12 post MI

Findings

  • Region 1:Paravertebral. –Myeloma, mets; extramedullary haemopoiesis, abscess, ganglioneuroma
  • Region 2: Dilated oesophagus- achalasia, hiatus hernia
  • Region 3: Aorta, Cardiac- aneurysm/ pseudoaneurysm

Diagnosis

Left ventricular pseudoaneurysm containing thrombus

  • Aneurysm:
    • Damaged myocardial wall, 90% anterior, 10% inferior, usually at the apex
    • Mouth wide or wider than its max diameter,
    • Approx 50% contain thrombus,
    • Almost never ruptures, risk decreases with time
    • Total occlusion of LAD with poor collaterals
    • 50% symptomatic CCF, 1/3 severe angina, 15% ventricular arrythmias main cause of mortality
  • Pseudoaneurysm:
    • Ruptured myocardium-wall is pericardium/pericardial adhesions
    • Virtually always contains thrombus and often ruptures
    • Usually the posterolateral wall of the LV
    • MI, rarely infection/ trauma

Treatment

  • Aneurysm treatment
    • Dor procedure +/- coronary revascularization: Aneurysmal resection and endocardial patching can improve LV function
    • Parachute Trial: Endovascular approach
  • Pseudoanerysm treatment:
    • Surgical emergency: resection
    • Important diagnosis for surgery (approach).
    • 10% surgical mortality vs approx 45% 12 month mortality with conservative treatment