Delayed traumatic left ventricular pseudoaneurysm: diagnostic challenges and surgical management

Abstract

Left ventricular (LV) pseudoaneurysms are uncommon, with traumatic cases being particularly rare. We present a case of a 26-year-old male with a delayed presentation of a traumatic LV pseudoaneurysm, 2 years post-blunt chest trauma. The patient experienced New York Heart Association (NYHA) grade 2 dyspnea, which prompted the investigation. Imaging studies, including X-ray, echocardiogram, and cardiac computed tomography (CT), revealed a large pseudoaneurysm arising from the LV apex, containing intramural thrombus. The surgical intervention involved the closure of the communicating orifice and on-lay pericardial patch placement. This case emphasizes the diagnostic challenges and successful management of traumatic LV pseudoaneurysms. Early detection through imaging and prompt surgical intervention led to a favorable outcome. This report contributes to understanding post-traumatic pseudoaneurysms and underscores the importance of a multidisciplinary approach in their management. Further studies are needed to refine diagnostic and treatment strategies for this rare condition.

Introduction

Left ventricular (LV) pseudoaneurysm is characterized by a contained rupture surrounded by adherent pericardium and is frequently linked with sequelae of myocardial infarction, post-cardiotomy, endocarditis, and infrequently, post-traumatic [1, 2]. The clinical presentation of such an occurrence tends to lack specificity, thereby presenting diagnostic challenges [3]. Urgent surgical intervention becomes imperative for this subset of patients due to the heightened risk of rupture [4].

Case summary

A 26-year-old male presented to the Cardiothoracic and Vascular Surgery Outpatient Department at our hospital with New York Heart Association (NYHA) grade 2 dyspnea on exertion persisting for the past 6 months. The patient reported a history of blunt chest trauma 2 years ago due to a fall from a motorcycle which was managed conservatively, with symptoms gradually subsiding.

Chest X-ray revealed gross cardiomegaly (Fig. 1). Routine investigations were within normal limits. An echocardiogram revealed a large LV pseudoaneurysm with LV apical and intramural thrombus, with an ejection fraction of 40–45%. Subsequent cardiac computed tomography (CT) confirmed a lobulated contrast-filled outpouching, approximately 17.5 × 10 × 11 cm in size, arising from the apex of the left ventricle. The CT coronary angiogram was normal. The pseudoaneurysm, contained by enhancing pericardium, extended inferiorly and posteriorly, indenting upon adjacent structures (Fig. 2).

Fig. 1.

X-ray of the patient showing cardiomegaly with the ill-defined apical region

Fig. 2.

CT image of patient showing LV pseudoaneurysm margins and communication from LV

The surgical intervention involved the identification and closure of the communicating orifice of the pseudoaneurysm using 2.0 polypropylene sutures in an interrupted manner, followed by the placement of an on-lay autologous pericardial patch to secure the closure while excluding the pseudoaneurysm cavity (Figs. 3 and 4). Intraoperative samples were sent for culture sensitivity and histopathological evaluation (HPE). While the culture report came out to be sterile, the HPE report was confirmative of a pseudoaneurysm sac.

Fig. 3.

a Visualization of pseudoanurysm sac. b Pseudoaneurysm sac seen to communicate with left ventricle

Fig. 4.

a Closure of communicating orifice of sac using margins of pseudoaneurysm. b Placement of an on-lay pericardial patch over the suture line

Discussion

LV pseudoaneurysms are uncommon cardiac sequelae, most frequently associated with myocardial infarction or post-cardiotomy states, with post-traumatic cases being exceedingly rare. Inayat et al. reported an overall incidence of LV pseudoaneurysms at 0.23%. Despite their rarity, LV pseudoaneurysms pose a significant risk of sudden death, estimated at 30–45%. Unlike true aneurysms, LV pseudoaneurysms are characterized by the absence of myocardial tissue in their walls, rendering them particularly prone to rupture [4].

The case presented here underscores the diagnostic challenges inherent in identifying LV pseudoaneurysms, especially when they manifest following trauma. Our patient’s delayed presentation, 2 years post-blunt chest trauma, underscores the necessity of maintaining a high index of suspicion for such complications in patients with a history of thoracic injury. This highlights the need for comprehensive imaging modalities for accurate diagnosis.

The combined use of echocardiogram and cardiac CT played a pivotal role in our patient’s diagnosis. Echocardiography provided initial suspicion, while cardiac CT offered detailed anatomical delineation, confirming the presence and extent of the LV pseudoaneurysm. This integrated diagnostic approach facilitated prompt surgical intervention, which is paramount given the heightened risk of rupture associated with LV pseudoaneurysms.

Although surgical repair of LV pseudoaneurysms carries inherent risks, including a reported mortality rate of 23–28%, it remains the standard of care due to the substantial risk of fatal rupture. Our case exemplifies the importance of early intervention, as timely surgical repair led to a favorable postoperative outcome and complete resolution of symptoms.

Conclusion

In summary, this case highlights the successful management of a delayed traumatic left ventricular pseudoaneurysm. Utilizing echocardiogram and cardiac CT for accurate diagnosis, early surgical intervention proved crucial in achieving a favorable outcome with symptom resolution. This report emphasizes the need for heightened clinical awareness and a multidisciplinary approach in addressing this rare condition. Further studies are warranted to enhance our understanding of post-traumatic pseudoaneurysms and refine optimal management strategies.

Funding

The authors certify that the research work did not receive any funding from any source.

Data availability

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Code availability

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Declarations

Ethical consideration

Institutional review board approval was not necessary because all the data were retrieved retrospectively.

Conflict of interest

The authors have no conflicts of interest to disclose.

Consent to participate

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Consent for publication

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