Distinguishing left ventricular aneurysm from pseudoaneurysm. A review of the literature

A postmyocardial infarction left ventricular pseudoaneurysm occurs when a rupture of the ventricular free wall is contained by overlying, adherent pericardium. A postinfarction aneurysm, in contrast, is caused by scar formation resulting in thinning of the myocardium. Although the usual treatment for patients with pseudoaneurysm is urgent surgical repair, the imaging characteristics of pseudoaneurysm and aneurysm, for which treatment is more conservative, are quite similar. The literature on the natural history and imaging characteristics of the two entities is reviewed, and an approach to distinguishing between the two entities is proposed.     

Noninvasive evaluation of a left ventricular pseudoaneurysm: complementary role of echocardiographic and nuclear techniques

This 45-year-old white male was evaluated for congestive heart failure initially ascribed to a rapidly progressive cardiomyopathy. Both radionuclide ventriculography and echocardiography correctly identified a left ventricular pseudoaneurysm as the cause for heart failure. Thallium-201 scintigraphy, by demonstrating a large perfusion defect, suggested a large ostium of the pseudoaneurysm. Following resection of the false aneurysm, a Dacron prosthesis was required to close a large posterior wall defect. We conclude that both radionuclide ventriculography and echocardiography can independently demonstrate a left ventricular pseudoaneurysm. The combined noninvasive approach is able to delineate various anatomical aspects of the pseudoaneurysm and help in planning adequate surgical intervention.     

Facile left ventricular deairing by administration of cardioplegia into the left ventricular vent

De-airing of left heart structures during minimally invasive valve operations is often difficult. A method of using a left ventricular vent temporarily hooked to the cardioplegia cannula for facile left ventricular deairing is described. Routine use of this simple method coupled with transesophageal echocardiography monitoring simplifies the process of left ventricular deairing in minimally invasive or standard valvular operations.     

Recurrent left ventricular false aneurysm

A recurrent left ventricular false aneurysm 5 years after patch repair and causing progressive congestive heart failure was readily diagnosed by echocardiography and heart catheterization. Its substrate was suture dehiscence of undetermined origin. Urgent repair was successful. The long-term prognosis is guarded.     

Congenital left ventricular apical aneurysm

An aneurysm of the left ventricular apex was accidently discovered on chest X-ray in an otherwise healthy 3 1/2-year-old-girl. Pre-operatively performed heart catheterization and ciné-angiography were followed by successful surgical removal of the aneurysm. Microscopic examination showed that the three layers of the myocardium were present, although it was degenerated by fibrosis. This case belongs to the fibrous type of aneurysm, which is the most rare type, not associated with other developmental defects, usually asymptomatic until there is rupture and sudden death, or the condition is accidentally discovered on chest X-ray and treated surgically.     

Overcoming right ventricular failure with left ventricular assist devices

BACKGROUND: Right ventricular failure can lead to circulatory collapse while on left ventricular assist device support. By shunting blood from the femoral vein to the left ventricular assist device, cardiac output can be increased, but arterial oxygen saturation will decrease. METHODS: To determine the effects on O2 delivery, a model was developed on the basis of O2 uptake in the lungs and whole body O2 consumption. An equation was derived that related cardiac output, pulmonary venous O2 saturation, O2 consumption, and the ratio of shunt-to-systemic blood flow to systemic O2 delivery. RESULTS: When total cardiac output increases, the shunt will increase systemic O2 delivery while decreasing arterial O2 saturation and leaving systemic venous O2 saturation unaltered. When total output does not increase, the shunt will decrease systemic O2 delivery, arterial O2 saturation, and systemic venous O2 saturation. CONCLUSIONS: The analysis suggests that measuring systemic venous oxygen saturation may be a useful way to monitor patient safety. A decrease in systemic venous O2 saturation when creating the shunt implies an inadequate increase in cardiac output.     

Right ventricular failure in patients requiring left ventricular assistance

Right ventricular failure may complicate isolated left ventricular assistance. In a series of 8 patients undergoing left ventricular assistance in postcardiotomy cardiogenic shock, right ventricular failure developed in 5, directly contributing to death in all cases despite initially satisfactory support. Difficulty in grafting a dominant right coronary artery was a common factor in all cases. Early consideration should be given to biventricular support under these circumstances.     

Right ventricular infarction during left ventricular assist system support

Clinical and pathologic findings are presented of the first reported case in the English-language medical literature of pseudomesotheliomatous adenocarcinoma (PMA) occurring in an HIV-infected patient. PMA is an uncommon variant of peripheral lung cancer which typically occurs in elderly male patients. It mimics a malignant mesothelioma in terms of its clinical presentation and gross and microscopic appearance. The occurrence of this rare tumor in a young HIV-infected patient suggests some association between HIV infection and the development of PMA.     

Left ventricular contractile performance, ventriculoarterial coupling, and left ventricular efficiency in hypertensive patients with left ventricular hypertrophy

Contractile performance of hypertrophied left ventricle may be depressed in arterial hypertension. Ventriculoarterial coupling is impaired when myocardial contractile performance is reduced and when afterload is increased. The left ventricular contractile performance and the ventriculoarterial coupling were evaluated in 30 hypertensive patients with moderate left ventricular hypertrophy and 20 control subjects. Left ventricular angiography coupled with the simultaneous recording of pressures with a micromanometer were used to determine end-systolic stress/volume index, the slope of end-systolic pressure-volume relationship, ie, end-systolic elastance, effective arterial elastance, external work, and pressure-volume area. In hypertensive patients, left ventricular contractile performance, as assessed by end-systolic elastance/ 100 g myocardial mass, was depressed (4.35 +/- 1.13 v 5.21 +/- 1.89 mm Hg/mL/100 g in control subjects P < .02), when end-systolic stress-to-volume ratio was comparable in the two groups (3.85 +/- 0.99 g/cm2/mL in hypertensive patients versus 3.51 +/- 0.77 g/cm2/mL in control subjects). Ventriculoarterial coupling, evaluated through effective arterial elastance/end-systolic elastance ratio, was slightly higher in hypertensive patients (0.53 +/- 0.08 v 0.48 +/- 0.09 mm Hg/mL in control subjects, P < .05), and work efficiency (external work/pressure-volume area) was similar in the two groups (0.78 +/- 0.04 mm Hg/mL in hypertensive patients versus 0.80 +/- 0.03 mm Hg/mL in control subjects). This study shows that despite a slight depression of left ventricular contractile performance, work efficiency is preserved and ventriculoarterial coupling is almost normal in hypertensive patients with left ventricular hypertrophy. Thus, it appears that left ventricular hypertrophy might be a useful means of preserving the match between left ventricle and arterial receptor with minimal energy cost.     

Postinfarction atrioventricular septal rupture

BACKGROUND: The development of venous access devices (VADs) and portable infusion pumps has enabled chemotherapy to be administered continuously within the home environment. AIM: The objective of this study was to describe the experience of establishing an ambulatory chemotherapy programme for patients receiving protracted infusions (PVIs) of 5-fluorouracil (5-FU). METHODS: The files of all patients receiving PVI 5-FU as a component of their treatment for gastrointestinal malignancy were reviewed. The types of VADs, infusion pump systems and their management were documented. Information packages and education programmes were developed for patients. RESULTS: Seventy-four patients with gastrointestinal cancer were studies. At the end of the period the Portacath was the preferred VAD, while both pumps used were found to have advantages and disadvantages. The choice of pump was decided more by patient preference than systematic differences in performance of the pumps. CONCLUSIONS: The findings in this review confirm that, with close attention to the potential pitfalls of ambulatory chemotherapy, an acceptable service can be provided.     

Contribution of long axis motion of left ventricular outflow to calculation of left ventricular stroke volume

Stroke volume can be calculated by using noninvasive Doppler techniques. The products of pulsed Doppler stroke distance of left ventricular outflow and left ventricular outflow area can often be used to calculate stroke volume. However, left ventricular outflow also moves longitudinally toward the apex of the ventricle during systole, so that zero velocity flow cannot be detected by the usual pulsed Doppler studies. We evaluated the contribution of these zero velocity flow to the noninvasive estimation of left ventricular stroke volume in 20 patients with left ventricular disease and in 20 age matched healthy controls. Left ventricular stroke distance was calculated by summing the Doppler stroke distance and the outflow long axis motion. The percentage of zero velocity flow for total stroke volume was calculated in each group. Cardiac output was also measured by thermo-dilution technique. The percentage of zero velocity flow for total noninvasive stroke volume in patients with left ventricular disease was 2.5 +/- 1.1 ml (4.0 +/- 1.5%), significantly lower than in normal subjects, 3.6 +/- 1.0 ml (5.5 +/- 1.5%) (p < 0.05). These long axis motions are significantly reduced, especially in left ventricular disease. Amplitudes of the left ventricular outflow long axis motion were correlated with Doppler stroke distance in all (r = 0.54, p < 0.01). In patients with myocardial infarction, stroke volume by thermo-dilution methods and calculated stroke volume showed good correlation both only by Doppler stroke distance (y = 1.044x + 0.547, r = 0.968) and by Doppler and long axis motion (y = 0.989x + 0.521, r = 0.974). Compared with stroke volume measured by thermodilution method, stroke volume calculated only by Doppler stroke distance was underestimated. We thus demonstrated the influence of zero velocity flow on left ventricular outflow both in patients with left ventricular disease and in normal subjects.     

A case of left ventricular myxoma

Left ventricular myxoma is very rare. To our knowledge, only 26 cases have been reported in the English and 7 cases in the Japanese literature. A 71-year-old man in our care was being followed due to angina pectoris. Two-dimensional echocardiography revealed a small mass in the left ventricular outflow tract. An operation was performed under cardiopulmonary bypass on July 14, 1992. A small mass located on the anterior wall of the left ventricle was excised en bloc via a transaortic approach. The gelatinous mass measuring 24 x 12 x 3 mm was determined histopathologically to be a myxoma. The postoperative course was uneventful and there has been no sign of recurrence so far. Because recurrent cases have been reported in the past, careful follow-up will be performed periodically.     

A case of left ventricular hemangioma

Left ventricle hemangioma in a 54-year-old man is reported. He was admitted to our hospital for chest discomfort. Coronary angiograms showed normal coronary arteries and a contrast blush in the left interventricle septum. Transesophageal echocardiogram also demonstrated the small floating tumor in the ventricular septum below the right coronary cusp. With the aid of cardiopulmonary bypass, the tumor was resected completely through transaortic approach. Histological examination revealed capillary hemangioma. The patient had uneventful recovery. To our knowledge, this is the seventh case of a left ventricular hemangioma treated surgically reported in the world literature.     

Ruptured left ventricular diverticulum in infancy

Congenital diverticulum of the left ventricle is rare, and rupture of such a diverticulum is even more rare. We describe successful surgical repair of a ruptured left ventricular diverticulum in an 11-month-old infant.