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).