JACC: CASE REPORTS VOL. -, NO.

-, 2022
ª 2022 THE AUTHORS. PUBLISHED BY ELSEVIER ON BEHALF OF THE AMERICAN

COLLEGE OF CARDIOLOGY FOUNDATION. THIS IS AN OPEN ACCESS ARTICLE UNDER

THE CC BY-NC-ND LICENSE (http://creativecommons.org/licenses/by-nc-nd/4.0/).

CASE REPORT

CLINICAL CASE

Decoding Postinfarction Left

Ventricular Pseudoaneurysm
Emily K. Nguyen, MD, PHD,a Promporn Suksaranjit, MD,b Mohammad A. Bashir, MD,c Dennis J. Firchau, MD,d
Milena A. Gebska, MD, PHD, MMEb

ABSTRACT

Recognizing true from pseudo left ventricular aneurysm after myocardial infarction is paramount to guide clinical
management and determine need for surgical urgency. We discuss a case of a postinfarction pseudoaneurysm that
poses unique anatomic challenges and may hold a secret “DaVinci code” beyond current diagnostic criteria.
(Level of Difficulty: Advanced.) (J Am Coll Cardiol Case Rep 2022;-:101533) © 2022 The Authors. Published by Elsevier
on behalf of the American College of Cardiology Foundation. This is an open access article under the CC BY-NC-ND license
(http://creativecommons.org/licenses/by-nc-nd/4.0/).

HISTORY OF PRESENTATION thrombus burden integrilin (eptifibatide) infusion

A 60-year-old man with multiple cardiovascular risks
initially presented with an acute infero-lateral ST-
segment elevation myocardial infarction (MI). He
underwent emergent coronary angiography and suc-
cessful primary percutaneous coronary intervention
with 2 drug-eluting stents to a large first obtuse
marginal branch of the left circumflex artery (culprit
vessel; right dominant system) (Figure 1). Given high
LEARNING OBJECTIVES

To gain insight into anatomy of the LV
pseudoaneurysm following an acute trans-
mural MI using multimodality imaging
modalities.

To highlight the importance of history of
presentation into clinical decision making in
patients presenting with LV aneurysm for-
mation after coronary reperfusion therapy.
was initiated while awaiting full effect of the P2Y 12
inhibitor. However, it was discontinued 50 minutes
later because of moderate pericardial effusion and
cardiac tamponade noticed on bedside transthoracic
echocardiography (TTE); mildly decreased left ven-
tricular (LV) systolic function with inferolateral
hypokinesis. Emergent pericardiocentesis confirmed
hemopericardium. No evidence of coronary artery
rupture was found on repeat coronary angiography.
The patient recovered well and was discharged on
day 3 on optimal goal-directed heart failure medical
therapy.
The patient was readmitted 20 days later with
worsening dyspnea. Contrast-enhanced TTE revealed
severe LV systolic dysfunction with an interim for-
mation of a large LV aneurysm with a broad
neck within the inferolateral segments (Figure 2A),
and no recurrent pericardial effusion. High-resolution
cardiac computed tomography (HRCT) angiography
helped further characterize the anatomy and

From the aDepartment of Internal Medicine, Carver College of Medicine, University of Iowa, Iowa City, Iowa, USA; bDivision of
Cardiovascular Medicine, Carver College of Medicine, University of Iowa, Iowa City, Iowa, USA; cDivision of Cardiothoracic Sur-
gery, Carver College of Medicine, University of Iowa, Iowa City, Iowa, USA; and the dDepartment of Pathology, Carver College of
Medicine, University of Iowa, Iowa City, Iowa, USA.
The authors attest they are in compliance with human studies committees and animal welfare regulations of the authors’
institutions and Food and Drug Administration guidelines, including patient consent where appropriate. For more information,
visit the Author Center.

Manuscript received April 18, 2022; revised manuscript received June 28, 2022, accepted July 4, 2022.

ISSN 2666-0849 https://doi.org/10.1016/j.jaccas.2022.07.005

2 Nguyen et al
Decoding Postinfarction Left Ventricular Pseudoaneurysm
ABBREVIATIONS remodeling of the LV chamber. A large
AND ACRONYMS aneurysmal sac (6.8  3.4 cm) involving mid-
to-apical lateral LV segments (Figure 2B) with
CMR = cardiac magnetic
resonance
a wide neck measuring 6.1  5.9 cm was
found with no obvious thrombus (Figure 2C,
HRCT = high-resolution cardiac
computed tomography Video 1). The calculated maximal internal
LV = left ventricle, left width of the aneurysmal orifice to the
ventricular maximal parallel internal diameter ratio of
MI = myocardial infarction 0.95 was greater than that classically ex-
TTE = transthoracic pected in pseudoaneurysm and pointed more
echocardiography toward a true aneurysm. HRCT was able to
identify thin walls of the LV aneurysm based on low
10.3 HU measurements, compared with the HU
ranging from 131.3 to 142.7 within the nonaneurysmal
LV segments (Figure 2D); altogether, these findings
raised concern for postinfarction pseudoaneurysm
formation and contained rupture. Three-dimensional
and volume-rendered HRCT reconstruction clearly
demonstrated that a large LV aneurysmal sac devel-
oped within the distribution of recently occluded and
reperfused large obtuse marginal branch (Figure 3,
Videos 2 to 4).
CLINICAL DECISION
Both LV “true” and “false” or “pseudo” aneurysms can
present with similar symptoms, hemodynamics,
physical examination, and nonspecific changes on
electrocardiogram.1-3 Given diagnostic uncertainty
based on imaging and high-risk features (recent
hemopericardium), a multidisciplinary team approach
was taken, including cardiologists, radiologists, and
cardiothoracic surgeons, to help facilitate genuinely
shared decision making between the care team and
the patient regarding high-risk surgery versus con-
servative approach. Ultimately, the patient accepted
perioperative risks and underwent open heart surgery.
F I G U R E 1 Emergent Coronary Angiography
(A) Occluded first obtuse marginal branch (arrows) with an intracoronary wire in situ before percutaneous coronary intervention and (B) after
reperfusion therapy. (C) Dominant right coronary artery (RCA). LAD ¼ left anterior descending; LCX ¼ left circumflex; RPDA ¼ right posterior
descending artery.
JACC: CASE REPORTS, VOL. -, NO. -, 2022
- 2022:101533
Intraoperative gross findings confirmed a large
pseudoaneurysm in the lateral LV wall with con-
tained rupture. A bovine pericardial patch was placed
on top of the closure line for LV remodeling and he-
mostasis (Figures 4A to 4C). Histopathological exam-
ination revealed a mixture of fibrous/granulation
tissue and organizing thrombus without any myo-
cytes (Figures 5A and 5B), ultimately confirming a
diagnosis of the LV pseudoaneurysm.
DISCUSSION
LV aneurysms are rare, but potentially life-
threatening sequelae following transmural MI. Early
and accurate diagnosis is paramount in directing
clinical care because LV pseudoaneurysms prompt
surgical emergency, whereas LV true aneurysms
rarely rupture. 4 True postinfarction LV aneurysm is
caused by a focal protrusion of all 3 layers of the LV
wall (the endocardium, myocardium, and epicar-
dium) ensuring stability. In contrast, LV pseudoa-
neurysm develops following a focal free wall rupture
approximately 10 days to 4 months from coronary
occlusion. As a result, hematoma protrudes through
the full thickness of the myocardium and becomes
contained by adherent pericardium or a scar tissue.1-4
Differentiation between LV true and false aneu-
rysm remains a clinical and anatomic challenge and
accurate diagnosis relies on imaging and pathology.
Until the 1990s, left ventriculography used to be the
gold standard modality with >85% accuracy.2 A
characteristic narrow neck and saccular dilatation in
the absence of surrounding coronary arteries would
support false aneurysm formation. 5 TTE continues to
be the first screening modality using similar criteria;
any orifice-to-pseudoaneurysm ratio of <0.5 suggests
pseudoaneurysm.6 Recent advances in cardiac HRCT
JACC: CASE REPORTS, VOL. -, NO. -, 2022 Nguyen et al 3
- 2022:101533 Decoding Postinfarction Left Ventricular Pseudoaneurysm

F I G U R E 2 Contrast-Enhanced 2-Dimensional Transthoracic Echocardiography and Anatomic Correlation With High-Resolution Cardiac Computed Tomography

Note a large-sized aneurysm of the left ventricular (LV) lateral wall with a wide neck typically seen in a “true” aneurysm. Thin walls of the LV aneurysmal sac with
relatively low Hounsfield Unit (HU) measurements raised concern for contained rupture and “false” or pseudoaneurysm. *Body of the LV lateral wall aneurysm.

angiography 3 and cardiac magnetic resonance (CMR)
imaging7 offer additional 3-dimensional
regarding the LV walls and coronaries. HRCT provides
a superior spatial resolution, and scan takes only few
minutes; it was the ideal imaging for our patient.
However, a definitive diagnosis remains difficult in
certain cases. The aneurysmal LV wall can be further
delineated by CMR given its tissue characterization
ability. Moreover, CMR shows increased sensitivity
for pericardial enhancement, which
commonly observed in LV pseudoaneurysms than
true aneurysms,7 but it would be technically chal-
lenging to perform during orthopnea. Our patient was
found to have a large LV outpouching in the territory
of the culprit left circumflex coronary artery distri-
details bution, 20 days after inferior-lateral ST-segment
elevation MI that posed anatomic and diagnostic
challenges. Based on infarct location, LV pseudoa-
neurysm was suspected because of its known stron-
ger predilection for the inferior/posterior and lateral
surface.1-3,8 There is a paucity of data to support
correlation between coronary dominance and post-
infarction LV pseudoaneurysm formation. The pres-
is more ence of hemopericardium early post- percutaneous
coronary intervention might have, in retrospect,
suggested “near miss” myocardial rupture. Interest-
ingly, our patient’s LV aneurysm anatomically
mimicked true aneurysm and did not meet current

F I G U R E 3 Postinfarction Left Ventricular Pseudoaneurysm

High-resolution cardiac computed tomography volume rendering reconstruction (A) and internal view (B) of postinfarction left ventricular
pseudoaneurysm. *Body of the left ventricular lateral wall aneurysm. OM ¼ obtuse marginal.
4 Nguyen et al JACC: CASE REPORTS, VOL. -, NO. -, 2022
Decoding Postinfarction Left Ventricular Pseudoaneurysm - 2022:101533

F I G U R E 4 Surgical Aneurysmectomy After Cardiopulmonary Bypass and Cardiac Arrest

(A) Aneurysm of the lateral wall extending to the apex, left ventricular vent is shown in the aneurysm cavity. Note clear demarcation of
whitish damaged myocardium. (B) Linear closure of aneurysm sack with felt, and multiple interrupted stitches placed in viable myocardium
around the aneurysm circumferentially. (C) The interrupted stitches used to place a bovine pericardial patch on top of the closure line for left
ventricular remodeling and hemostasis.

morphological criteria for LV pseudoaneurysm. Initial
TTE imaging suggested true LV aneurysm based on a
broad neck. Notably, Yeo et al 8 reported wide neck in
postinfarction pseudoaneurysms. Although HRCT
displayed orifice-to-pseudoaneurysm ratio $0.5,2 it
also demonstrated thin walls with relatively low HU
pointing toward contained rupture. The authors were
unable to apply the concept of myocardial “cut-off
sign” based on tapering of sac wall thickness seen on
HRCT imaging to confidently diagnose a pseudoa-
neurysm.7 Intraoperative examination solidified the
diagnoses on false aneurysm that was confirmed by
lack of myocardial tissue on histological examination.
This case highlights the anatomic variation and
imaging limitations in diagnosing postinfarction LV
pseudoaneurysm versus true aneurysm. The authors
would like to highlight that current diagnostic criteria
may not apply to all cases, therefore additional
deductive knowledge and multidisciplinary expertise
may be required in some cases to reach a correct
diagnosis.
CONCLUSIONS
LV pseudoaneurysm formation is a rare and life-
threatening complication of acute MI. Postinfarction
pseudoaneurysm can present with a “wide neck” and
anatomically mimic true LV aneurysm on multi-
modality imaging. Therefore, orifice-to-
pseudoaneurysm ratio should not be solely used as a
diagnostic criterion. It our case, HRCT and wall
thickness/radiologic density measurements together

F I G U R E 5 Hematoxylin and Eosin Histologic Examination of the Left Ventricular Specimen Confirmed the Diagnosis of Pseudoaneurysm

Aneurysmal specimen revealed fibrous tissue with granulation tissue and organizing thrombus, and no myocardium, consistent with a “false”
aneurysm of the heart. (A) Magnification ¼ 2; (B) 5.
JACC: CASE REPORTS, VOL. -, NO. -, 2022
- 2022:101533
with clinical context helped overcome diagnostic
uncertainty and prompted surgical intervention.
FUNDING SUPPORT AND AUTHOR DISCLOSURES
The authors have reported that they have no relationships relevant to
the contents of this paper to disclose.
REFERENCES
1. Van Tassel RA, Edwards JE. Rupture of heart
complicating myocardial infarction. Analysis of 40
cases including nine examples of left ventricular
false aneurysm. Chest. 1972;61:104–116.
2. Frances C, Romero A, Grady D. Left ventricular
pseudoaneurysm. J Am Coll Cardiol. 1998;32:557–
561.
3. Hulten EA, Blankstein R. Pseudoaneurysms of
the heart. Circulation. 2012;125:1920–1925.
4. Vlodaver Z, Coe JI, Edwards JE. True and false
left ventricular aneurysms. Propensity for the
altter to rupture. Circulation. 1975;51:567–572.
Nguyen et al 5
Decoding Postinfarction Left Ventricular Pseudoaneurysm
ADDRESS FOR CORRESPONDENCE: Dr Milena A.
Gebska, Division of Cardiovascular Medicine, Carver
College of Medicine, University of Iowa, 200 Hawkins
Drive, Iowa City, Iowa 52242, USA. E-mail:
milena-gebska@uiowa.edu.
5. al-Saadon K, Walley VM, Green M, left ventricular pseudoaneurysms from true an-
Beanlands DS. Angiographic diagnosis of true and eurysms. J Thorac Imaging. 2022;37:58–65.
false LV aneurysms after inferior wall myocardial
8. Yeo TC, Malouf JF, Reeder GS, Oh JK. Clinical
infarction. Cathet Cardiovasc Diagn. 1995;35:266–
characteristics and outcome in postinfarction
269.
pseudoaneurysm. Am J Cardiol. 1999;84:592–595.
6. Gatewood RP Jr, Nanda NC. Differentiation of
left ventricular pseudoaneurysm from true aneu-
rysm with two dimensional echocardiography. Am KEY WORDS acute myocardial infarction,
J Cardiol. 1980;46:869–878. complications, coronary artery disease,
pseudoaneurysm
7. Ballard DH, Jokerst C, Raptis CA, Pilgram TK,
Woodard PK. Myocardial cut-off sign is a sensitive
and specific cardiac computed tomography and A PPE NDI X For supplemental videos,
magnetic resonance imaging sign to distinguish please see the online version of this paper.