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\begin{document}

\title{Left Ventricular and adjacent Right ventricular Pseudoaneurysms post
acute myocardial infarction communicating via a Ventricular Septal
Defect}



\author[1]{Kevin Kang}%
\author[2]{John Wilson}%
\author[2]{Jeffrey Friedel}%
\author[3]{Angel Flores}%
\affil[1]{Dartmouth College Geisel School of Medicine}%
\affil[2]{Meadville Medical Center}%
\affil[3]{Butler Memorial Hospital}%


\vspace{-1em}



  
  \date{May 28, 2024}


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\selectlanguage{english}
\begin{abstract}
The rare but deadly post myocardial infarction (MI) mechanical
complications are categorized as ventricular free wall rupture,
ventricular septal rupture (VSD) and papillary muscle rupture in
decreasing order of incidence. The incidence of the mechanical
complications has been mitigated by early revascularization in recent
years but mortality remains high. The cardiac rupture if contained by
clot, scar and pericardium leads to a LV pseudoaneurysm that delays or
diminishes the fatal outcome. Mechanical complications and
pseudoaneurysm are recognized by echocardiography. We report a
previously unreported occurrence of a pseudoaneurysm involving the
adjacent walls of both the ventricles, LV basal and inferoseptal walls
and the adjacent right ventricular inferior wall (RV). The LV and RV
communicated via a hole in the pseudoaneurysmal wall. The
echocardiographic images initially showed the LV pseudoaneurysm bulging
into the RV rather than into the pericardium. The color Doppler showed
shunting through the LV pseudoaneurysm into the RV creating an unusual
VSD. The CT angiograms corroborated the echo findings. The LV
pseudoaneurysm had a tear in it and this led to bleeding not into
pericardium but into the adjacent RV pseudoaneurysm, hence creating a
very unusual VSD. Subsequently, our patient went for surgical repair of
pseudoaneurysm and the surgical findings confirmed the imaging findings
that there was a massive LV pseudoaneurysm from the inferior and
inferoseptal walls, the adjacent RV wall was involved with the
pseudoaneurysm and a communication between LV pseudoaneuysm sac and the
RV was seen. Such pathology has not been described in the past.%
\end{abstract}%



\sloppy


TITLE PAGE

TITLE: Left Ventricular and adjacent Right ventricular Pseudoaneurysms
post acute myocardial infarction communicating via a Ventricular Septal
Defect

AUTHORS:

1. Kevin Kang BA, MD candidate (corresponding author)

Dartmouth Geisel School Of Medicine, Hanover, NH 03755.

Email: kevinsinghkang@gmail.com

2. John Wilson MD

Meadville Medical Center, Meadville, PA USA.

Email: JWilson1@mmchs.org

3. Jeffrey Friedel MD

Meadville Medical Center, Meadville, PA USA.

Email: Jfriedel@mmchs.org

4. Angel Flores MD

Butler Hospital, Butler PA USA.

Email: arfa@aol.com

Institution where the work was performed: Meadville Medical Center

Short running head title: LV and RV pseudoaneurysms creating a VSD

Key words: pseudoaneurysm; rupture; septum

Financial Support: None

Type of article: Case Report

Corresponding author's Fax number, telephone number and email address
respectively: K. Kang 814-450-8160 and kevinsinghkang@gmail.com

Home address: 4368 Winners Circle, Erie PA 16506

Title: Left Ventricle and adjacent Right ventricle Pseudoaneurysms post
myocardial infarction communicating via a Ventricular Septal Defect

Abstract

The rare but deadly post myocardial infarction (MI) mechanical
complications are categorized as ventricular free wall rupture,
ventricular septal rupture (VSD) and papillary muscle rupture in
decreasing order of incidence. The incidence of the mechanical
complications has been mitigated by early revascularization in recent
years but mortality remains high. The cardiac rupture if contained by
clot, scar and pericardium leads to a LV pseudoaneurysm that delays or
diminishes the fatal outcome. Mechanical complications and
pseudoaneurysm are recognized by echocardiography. We report a
previously unreported occurrence of a pseudoaneurysm involving the
adjacent walls of both the ventricles, LV basal and inferoseptal walls
and the adjacent right ventricular inferior wall (RV). The LV and RV
communicated via a hole in the pseudoaneurysmal wall. The
echocardiographic images initially showed the LV pseudoaneurysm bulging
into the RV rather than into the pericardium. The color Doppler showed
shunting through the LV pseudoaneurysm into the RV creating an unusual
VSD. The CT angiograms corroborated the echo findings. The LV
pseudoaneurysm had a tear in it and this led to bleeding not into
pericardium but into the adjacent RV pseudoaneurysm, hence creating a
very unusual VSD. Subsequently, our patient went for surgical repair of
pseudoaneurysm and the surgical findings confirmed the imaging findings
that there was a massive LV pseudoaneurysm from the inferior and
inferoseptal walls, the adjacent RV wall was involved with the
pseudoaneurysm and a communication between LV pseudoaneuysm sac and the
RV was seen. Such pathology has not been described in the past.

Manuscript

Introduction:

Acute myocardial infarction can be associated rarely with deadly
mechanical complications resulting from myocardial rupture (1,2). The
types of mechanical complications are categorized as ventricular free
wall rupture (FWR), ventricular septal rupture (VSD) and papillary
muscle rupture (PMR) in decreasing order of incidence (2,3). The FWR has
been reported in up to 10\% (dropping to 2\% currently) of Mis in
pre-reperfusion era while VSD and PMR had a lower incidence of 1-2\% and
0.5-5\%, respectively (3). The risk of these complications has been
reduced by early revascularization, but the consequences stay
devastating with very high mortality. Left ventricular free wall rupture
has very high mortality post myocardial infarction (MI) but if the left
ventricle (LV) is not communicating freely with pericardium, the
consequences are mitigated and mortality delayed or reduced. This can
happen due to formation of a pseudoaneurysm (PSA) at the site of
rupture. The tear in the myocardial wall is contained by the
pseudoaneurysm wall, which is formed by the adherent clot, scar tissue
and adjacent visceral pericardium that balloons out into the parietal
pericardium (4). This process stops the left ventricular bleeding
because the cardiac rupture is contained by adherent pericardium or scar
tissue, which are forming the thin pseudoaneurysm wall (4). Thus, unlike
a true LV aneurysm, a LV pseudoaneurysm contains no endocardium or
myocardium (4). Wall stress, which is related to LV pressure, LV radius,
and importantly LV wall thickness along with the loss of myocardial
integrity (from myocardial infarction) are the likely determinants of
the subsequent cardiac rupture and free catastrophic bleeding into
pericardial cavity (5). As noted, most commonly, the initial free wall
intra-pericardial rupture results in cardiac tamponade and sudden death
but less frequently, cardiac rupture is contained and LV pseudoaneurysm
formation occurs (6,7). However, in a patient presenting with normal
blood pressure and contained free wall rupture, the diagnosis of LV
pseudoaneurysm is difficult as it is uncommon but also costly to miss
because of the near certain mortality of the rupture of the
pseudoaneurysm wall (8,9). Post-infarct ventricular septal defect
(PIVSD) can be another devastating complication of acute myocardial
infarction (MI). In the pre-reperfusion era, the VSD prevalence was 1\%
to 3\%, dropping to 0.2\% with reperfusion (6). Both ventricular septal
defect (VSD) and pseudoaneurysms can be recognized by echocardiography
(10). We present a case of a pseudoaneurysm involving both the basal
inferoseptal wall of the left ventricle and the adjacent right ventricle
(RV) along with an unusual VSD. The left ventricle communicated with the
right ventricle (RV) through the pseudoaneurysm sac.

Case Presentation:

66-year-old male was a cardiology outpatient on June 19, 2018 for chest
pressure that he experienced on May 26, 2018. An electrocardiogram (ECG)
from June 11, 2018 showed evidence of age indeterminate inferior
myocardial infarction. Stress perfusion imaging was done on June 25,
2018 and was low risk. He walked over 6 minutes on Bruce protocol and
the test showed inferior-septal infarct and no ischemia. Two weeks
later, his symptoms worsened, and he came to cardiology office on July
13, 2018. A new holosystolic murmur was heard. An emergent
echocardiogram showed a ventricular septal defect (VSD) and
pseudoaneurysm involving the basal inferior wall. An emergent coronary
angiogram was done in our referring hospital that showed that the right
coronary artery was occluded, and this was left occluded.~An
intra-aortic balloon pump was placed. Right heart catheterization or
left ventricular angiogram was not done. The patient was then
transferred to our tertiary care hospital that has open-heart surgery
capability.

A repeat echocardiogram at our institution was done upon arrival.
4-chamber showed a large pseudoaneurysm that involved the inferoseptal
wall (Figure 1 and Video 1). Several echocardiographic views revealed
that the pseudoaneurysm bulged into the RV rather than the pericardium
only (Figure 2 and Video 2). The pseudoaneurysm, despite taking several
views, was never seen without also visualizing the adjacent right
ventricle leading to the eventual surgical findings showing that the
even the right ventricle adjacent to the inferior septum was
pseudoaneurysmal. A VSD had been formed between the LV pseudoaneurysm
sac and the adjacent right ventricular pseudoaneurysm sac. The VSD was
noted by color Doppler showing that the flow into the pseudoaneurysm sac
could be followed through a tear in the pseudoaneurysm wall into the
right ventricle with associated moderate tricuspid regurgitation seen as
well (Figures 3 and Video 3). The impingement from LV pseudoaneurysm and
also the VSD jet may have contributed to the tricuspid regurgitation jet
(Figure 4 and Video 4). Again, this was confirmed by surgical findings
even though the saline bubble injection failed to show communication
between left ventricle and right ventricle. Indeed, the bubbles were
entering the pseudoaneurysm chamber through the narrow-necked tear in
the inferoseptal wall but the pressure inside the pseudoaneurysm sac was
not high enough for bubbles to enter the RV. Anteroseptal wall was
intact as seen on subcostal echo images but pseudoaneurysm sac was still
visible in the RV illustrating the large sized pseudoaneurysm and its
relationship with the RV (Figure 5). Short axis views showed that the
basal inferior and inferoseptal wall had a hole in it and was bulging
out as a pseudo aneurysm into the adjacent RV and the inferior wall of
the RV adjacent to the septum was also suspicious for pseudoaneurysm as
later confirmed surgically (Figure 6).

A CT angiogram confirmed that the LV had thinning of the inferior wall
and a very large pseudoaneurysm was projecting into the pericardium and
also towards the RV with the adjacent inferior wall of RV bulging
inferiorly as well (Figure 7). The opening of LV pseudoaneurysm through
a hole into the RV pseudoaneurysm creating a VSD could also be seen on
CTA (Figure 8). The open surgical repair confirmed the above remarkable
scenario with both LV and RV involved with pseudoaneurysms and the LV
pseudoaneurysm sac communicated with RV creating an unusual VSD.

As above, the patient was taken to the operating room and the open
surgical evaluation revealed a very large and complex left ventricular
pseudoaneurysms and even an adjacent RV pseudoaneurysm. OR findings
confirmed the echo and CT findings that both the inferior/inferoseptal
walls of the left ventricle had blown out into a large pseudoaneurysm.
~The adjacent inferior right ventricle was involved by the
pseudoaneurysm and the 2 ventricles communicated through the
pseudoaneurysm sac.

Our patient's echocardiogram pre surgery with massive hole in
inferoseptum (Figure 9) can be contrasted with his echocardiogram
immediately post surgery with intact inferoseptum (Figure 10). On post
surgical echo imaging, he had no pseudoaneurysm and no shunting.
Subsequent to the surgery, our patient underwent rehabilitation post
discharge. He has been seen in our outpatient cardiology office more
than two years after surgery and he has been asymptomatic with excellent
exercise tolerance.

Discussion:

We present an unusual case of a huge pseudoaneurysm involving both the
basal inferior wall and inferior septum but even the adjacent RV
inferior wall. The pseudoaneurysm ruptured straight into the right
ventricle instead of the pericardial cavity and this caused a tiny VSD
instead of tamponade (9).

Mechanical complications of FWR, VSD and papillary muscle rupture have
become rarer in the reperfusion era but still present with devastating
complications of MI like cardiogenic shock (1,2). Patients often present
with single-vessel coronary artery disease and usually do not have a
positive history for a previous myocardial infarction (1,2,3). The
incidence of post infarction angina in these patients is significantly
greater than in patients without ventricular rupture (1,2,3). Delay in
treatment and continued physical activity post infarction increases the
risk of ventricular rupture (1,2,3).

Imaging is critical to diagnosis of mechanical complications of acute
MI. Our echocardiographic images after the patient's presentation showed
that the LV inferoseptal wall with an unusual pseudoaneurysm that bulged
into the adjacent RV. The color Doppler suggested shunting through the
LV pseudoaneurysm into the RV creating an unusual VSD. The CT angiograms
corroborated the echo findings. Subsequently, our patient went for
surgical repair of pseudoaneurysm and the open surgical findings
confirmed the imaging findings that there was a massive LV
pseudoaneurysm from the inferior and inferoseptal walls, the RV was
involved with pseudoaneurysm of its inferior wall adjacent to the septum
and a communication with LV pseudoaneuysm sac and the RV causing a
previously described VSD was seen.

Conclusion:

The co-occurrence of VSD with pseudoaneurysm formation or concurrent LV
and RV double rupture are very rare but have been reported (11,12). The
clinical scenario in our patient of having concomitant pseudoaneurysm of
LV and adjacent RV leading to an unusual VSD with communication between
the two ventricles created by a tear in pseudoaneurysm sac has never
been reported in the past. Our patient's unique pathology was suggested
by echocardiography and CT angiographic findings and then confirmed
during the open surgical repair.

References:

\begin{enumerate}
\tightlist
\item
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  PG, Eagle KA, Cantador JR, Fitzgerald G, Granger CB. Factors related
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\item
  Koeda Y, Itoh T, Ishikawa Y, et al. A multicenter study on the
  clinical characteristics and risk factors of in-hospital mortality in
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  infarction {[}published online ahead of print, 2020 Apr
  1{]}.~\emph{Heart Vessels} . 2020;10.1007/s00380-020-01586-0.
  doi:10.1007/s00380-020-01586-0
\item
  Davis N, Sistino JJ.~Review of ventricular rupture: key concepts and
  diagnostic tools for success.~Perfusion~2002;17:63--7.
\item
  Craig~Frances,~Anthony~Romero,~Deborah~Grady. Left ventricular
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  1998,~32~(3)~557-561;~DOI:10.1016/S0735-1097(98)00290-3.
\item
  Mark C.K.~Hamilton,~Jonathan C.L.~Rodrigues,~Robin P.~Martin,~Nathan
  E.Manghat,~Mark S.~Turner. The In~Vivo Morphology of Post-Infarct
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  2017,~10~(12)~1233-1243;~DOI:10.1016/j.jcin.2017.03.042.
\item
  Bates ER. Reperfusion therapy reduces the risk of myocardial rupture
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\item
  Vlodaver Z, Coe 11. Edwards lE. True and false left ventricular
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\item
  Catherwood E, Mintz GS, Kotler MN, Parry WR, Segal BL. Two-dimensional
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  Gatewood RP, Nanda NC. Differentiation of left ventricular
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  echocardiography. Am J Cardiol 1980;46:869-78.
\item
  Recusani F, Raisaro A, Sgalambro A, et al. Ventricular septal rupture
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\item
  Hamilton K. Ellenbogen K. Lowe JE. Kisslo J. Ultrasound diagnosis of
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\item
  Chen S-J, Zhang C, Meng Q-T, Peng Y, Chen M. Sudden death due to
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\end{enumerate}

Figures and Videos (videos in Supplementary Material) :

Figure 1 and Video 1. 4 chamber view showing the basal inferior septum
(INFEROSEP) with a large pseudoaneurysm (PSA) creating a VSD and bulging
into the right ventricle.

Figure 2 and Video 2: Subcostal view again showing the large
pseudoaneurysm coming off the base of the inferior septal wall.

Figure 3 and Video 3: Subcostal view showing that through the
pseudoaneurysm sac, there is a VSD leading to a communication between
the LV and the RV

Figure 4 and Video 4. Four chamber view again supporting the unusual VSD
through the sac of the pseudoaneurysm into the RV as well as associated
tricuspid regurgitation.

Figure 5 and Video 5: Dramatic subcostal view of the pseudoaneurysm
showing that the anterior septum (ANTSEP) is intact and the bulging
pseudoaneurysm from the inferoseptal wall is seen in the right
ventricle.

Figure 6: Short axis view showing that the basal inferior and
inferoseptal wall has a hole in it and is bulging out as a pseudo
aneurysm into the adjacent RV

Figure 7. CT angiogram (CTA) showing that the basal LV inferior wall is
thinned out with an inferior wall pseudoaneurysm and adjacent RV
inferior wall aneurysm

Figure 8. CT angiogram showing the pseudoaneurysm part of the LV that
communicates via a hole (VSD) into the RV pseudoaneurysm

Figure 9. Presurgical echo subcostal images illustrate the narrow neck
in inferoseptal wall into a giant pseudoaneurysm

Figure 10. Post surgical repair now showing an intact inferoseptal wall.\selectlanguage{english}
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