What is the diagnosis?
Answer: new-onset heart failure with rare concomitant occurrence of VSR and LVA secondary to silent inferior infarction
An echocardiogram (TTE) revealed a 4.5 cm left ventricular aneurysm (LVA) extending from the base to mid-section of the inferoseptum (Figure 1A) and a ventricular septal defect (VSD) of 1.5 cm in mid-ventricular septum (Figure 1B) with an estimated Qp:Qs of 1.6. Heparin was discontinued, and patient continued treatment for heart failure. Cardiac magnetic resonance imaging (CMR) was obtained to further characterize the mechanical complications from suspected old inferior infarction, which showed a 6 cm inferior wall LVA (Figure 2A) and a 0.8 cm inferobasal VSD (Figure 2B). Coronary angiography showed 90% stenosis of the proximal right coronary artery (RCA) with severe diffuse distal disease (Figure 3A) and a 50% focal napkin ring lesion of the proximal left main coronary artery (Figure 3B). Coronary artery bypass graft (CABG) and left ventriculoplasty were subsequently performed with left internal mammary artery to left anterior descending artery and saphenous vein graft to obtuse marginal artery. The LVA was resected and the VSR was repaired using a Dacron Patch. Post-surgery TTE showed successful LVA repair (Figure 4A) and resolution of previous VSR without residual interventricular shunt (Figure 4B). Our case demonstrated a rare concomitant occurrence of VSR and LVA secondary to silent inferior infarction. Given the high mortality, clinicians should be vigilant in their evaluation for post-MI mechanical complications (1). A multimodality approach can facilitate the diagnosis and management of these complications. Although surgical repair remains the definitive treatment for VSR and selectively indicated in certain LVA cases, the optimal timing should be considered in an individualized fashion (1).