Right Ventricular False Aneurysm After Unrecognized Myocardial Infarction 28 Years Previously by Hannibal Baccouche, Adrian Ursulescu, Ali Yilmaz, German.

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Presentation transcript:

Right Ventricular False Aneurysm After Unrecognized Myocardial Infarction 28 Years Previously by Hannibal Baccouche, Adrian Ursulescu, Ali Yilmaz, German Ott, Karin Klingel, Manfred Zehender, and Heiko Mahrholdt Circulation Volume 118(20):2111-2114 November 11, 2008 Copyright © American Heart Association, Inc. All rights reserved.

Figure 1. Abdominal computed tomography scan with oral contrast agent. Figure 1. Abdominal computed tomography scan with oral contrast agent. The unclear mass, located at a left anterior position on the cranial side of the diaphragm and related to the apical portions of the heart, is indicated by the arrowhead. Panels I to IV appear in cranio-caudal order. Hannibal Baccouche et al. Circulation. 2008;118:2111-2114 Copyright © American Heart Association, Inc. All rights reserved.

Figure 2. Twelve-lead ECG reveals a 75° electrical axis and high R-amplitudes in chest leads V2 and V3. Figure 2. Twelve-lead ECG reveals a 75° electrical axis and high R-amplitudes in chest leads V2 and V3. Hannibal Baccouche et al. Circulation. 2008;118:2111-2114 Copyright © American Heart Association, Inc. All rights reserved.

Figure 3. Right ventricular ECG leads show discrete ST-segment elevations (rV1 to rV4) and negative T waves (rV2 to rV6). Figure 3. Right ventricular ECG leads show discrete ST-segment elevations (rV1 to rV4) and negative T waves (rV2 to rV6). Hannibal Baccouche et al. Circulation. 2008;118:2111-2114 Copyright © American Heart Association, Inc. All rights reserved.

Figure 4. Transthoracic echocardiographic images (TTE) of multiple long- and short-axis views (LAX and SAX) displayed in the top and bottom row. Figure 4. Transthoracic echocardiographic images (TTE) of multiple long- and short-axis views (LAX and SAX) displayed in the top and bottom row. Because of poor acoustics and infero-apical location, the right ventricular false aneurysm could not be detected by echo. The right ventricular cavity and the right ventricular apex are indicated by arrowheads. For full motion images, see the online-only Data Supplement. Hannibal Baccouche et al. Circulation. 2008;118:2111-2114 Copyright © American Heart Association, Inc. All rights reserved.

Figure 5. Steady-state free precession CMR images of multiple long-axis views are displayed in the upper 2 rows (diastole and systole). Figure 5. Steady-state free precession CMR images of multiple long-axis views are displayed in the upper 2 rows (diastole and systole). The right ventricular false aneurysm is located infero-apically as indicated by arrows, measuring 37×27 mm. Contrast CMR images are displayed in the bottom row revealing late gadolinium enhancement in large portions of the mass (arrowheads) For full motion images, see the online-only Data Supplement. Hannibal Baccouche et al. Circulation. 2008;118:2111-2114 Copyright © American Heart Association, Inc. All rights reserved.

Figure 6. The time-resolved gadolinium contrast bolus tracking sequence (steady-state free precession) in horizontal and vertical long-axis views (4-chamber view; right-sided 2-chamber view). Figure 6. The time-resolved gadolinium contrast bolus tracking sequence (steady-state free precession) in horizontal and vertical long-axis views (4-chamber view; right-sided 2-chamber view). Note the gadolinium passage from the right ventricular cavity by a thin mouth (5 mm in diameter [marked by arrowhead]) into the mass. For full motion images, see the online-only Data Supplement. Hannibal Baccouche et al. Circulation. 2008;118:2111-2114 Copyright © American Heart Association, Inc. All rights reserved.

Figure 7. Invasive coronary angiography displays a prominent proximal plaque (indicated by arrowheads) in the dominant left circumflex artery (RCX) supplying the region of the aneurysm as demonstrated by right ventriculography. Figure 7. Invasive coronary angiography displays a prominent proximal plaque (indicated by arrowheads) in the dominant left circumflex artery (RCX) supplying the region of the aneurysm as demonstrated by right ventriculography. The plaque-related lumen reduction is not hemodynamically significant (40%). The other vessels are without pathological findings. Hannibal Baccouche et al. Circulation. 2008;118:2111-2114 Copyright © American Heart Association, Inc. All rights reserved.

Figure 8. A, Operative situs displaying the infero-apical topography of the false aneurysm (FA). Figure 8. A, Operative situs displaying the infero-apical topography of the false aneurysm (FA). B and C, Surgical removal and direct closure (indicated by arrowheads). D, Histology (Masson trichrome staining). Note the endocardial (I) and epicardial layer (II). Only neovasculature (III) and fibrosis (IV) are apparent within the aneurysm wall in the absence of myocardial fibers. E, Magnification of endoluminal extract, displaying band-like fibrosis of the subendothelial layer. F, The absence of myocardial fibers is confirmed by desmin immunostaining. The positive desmin reactivity of a small vessel serves as internal control (arrowheads). Hannibal Baccouche et al. Circulation. 2008;118:2111-2114 Copyright © American Heart Association, Inc. All rights reserved.