CASE REPORT

Pseudoaneurysm with left-to-right shunt in a patientwith myocardial infarction: evaluation by three-dimensionalechocardiography

Hirofumi Maeba • Yoko Miyasaka •

Ayako Kotaka • Satoshi Tsujimoto •

Fumio Yuasa • Toshiji Iwasaka

Received: 7 October 2011 / Accepted: 17 January 2012 / Published online: 7 April 2012

� The Japan Society of Ultrasonics in Medicine 2012

Abstract It is often difficult to noninvasively differenti-

ate a post-infarction left ventricular (LV) pseudoaneurysm

from a post-infarction true aneurysm. A 66-year-old

woman with a past history of inferior acute myocardial

infarction was admitted to our hospital because of acute

decompensated heart failure. Two-dimensional transtho-

racic echocardiography showed an aneurysm with a narrow

orifice in the inferoposterior basal area. The pulmonary to

systemic flow ratio (Qp/Qs) was 2.2:1, which corresponded

to moderate left–right shunting. Three-dimensional trans-

esophageal echocardiography (3D-TEE) showed the orifice

in the perforated right ventricular basal area with a color jet

through the orifice from the LV to the right ventricle.

Collectively, based on the 3D-TEE findings, we diagnosed

the case as inferoposterior pseudoaneurysm with a left-to-

right shunt caused by myocardial infarction.

Keywords Pseudoaneurysm � Left-to-right shunt �Three-dimensional transesophageal echocardiography

Introduction

A post-infarction left ventricular (LV) pseudoaneurysm

develops when the ventricular free wall is ruptured and

contained by overlying adherent pericardium. A post-

infarction true aneurysm, in contrast, is caused by scar

formation resulting in the thinning of the myocardium [1]. It

has been reported that a post-infarction LV pseudoaneu-

rysm is a rare complication, accounting for approximately

2% of all LV aneurysm cases [2, 3]. Contrast ventriculog-

raphy, radionuclide ventriculography, and magnetic reso-

nance imaging (MRI) have been used as diagnostic

approaches to distinguish between the two entities. Here,

we report a patient with a post-infarction LV pseudoaneu-

rysm with a left-to-right shunt evaluated by three-dimen-

sional transesophageal echocardiography (3D-TEE).

Case report

A 66-year-old woman with a past history of cerebral

infarction was referred to our coronary care unit (CCU)

because of chest pain. From electrocardiography (ECG)

findings with ST elevation, inferoposterior myocardial

infarction was diagnosed. Emergency coronary angiogra-

phy revealed triple vessel disease (#6: 90%, #3: 100%, #13:

90%) (Fig. 1). The culprit lesion in the right coronary

artery was reperfused with a bare metal stent within 6 h

after onset. The residual stenosis in the left descending

artery and left circumflex artery was reperfused electively

with a drug-eluting stent. Although all coronary artery

branches were reperfused successfully with TIMI 3 flow,

myocardial scintigraphy with 99mTc-tetrofosmin revealed

that myocardial viability in the inferoposterior basal area

was not preserved (Fig. 2). Consequently, she was dis-

charged on the 19th day without cardiac complication.

On the 29th day, she was referred to our CCU again as a

result of progressive dyspnea. Physical examination

revealed peripheral edema of the lower limbs and signs of

raised jugular venous pressure. No abdominal abnormali-

ties were found. Neurological examination revealed

abnormalities because of the previous cerebral infarction.

H. Maeba (&) � Y. Miyasaka � A. Kotaka � S. Tsujimoto �F. Yuasa � T. Iwasaka

Division of Cardiovascular Disease,

Department of Medicine II, Kansai Medical University,

2-3-1 Shinmachi, Hirakata, Osaka 573-1191, Japan

e-mail: maebah@hirakata.kmu.ac.jp

123

J Med Ultrasonics (2012) 39:169–172

DOI 10.1007/s10396-012-0355-x

Her heart rate was regular, 113 beats/min, and her arterial

blood pressure was 142/113 mmHg. Auscultation of the

lungs and heart revealed bilateral basal inspiratory rales

and a grade 4/6 holosystolic murmur, respectively. Chest

radiography revealed a cardiothoracic ratio of 90% with

pulmonary congestion and pulmonary effusion. ECG

demonstrated ST-segment elevation inferiorly, which was

similar to the control ECG at discharge. Two-dimensional

transthoracic echocardiography (2D-TTE) and 2D-TEE

showed an aneurysm with a narrow orifice in the infero-

posterior basal area (Figs. 3, 4). Pulsed Doppler by

2D-TTE showed turbulent flow at the neck of a cavity and

within the cavity itself (Fig. 5). The pulmonary to systemic

flow ratio (Qp/Qs) was 2.2:1, which corresponded to

moderate left–right shunting. Pulsed Doppler by 2D-TEE

indicated a left-to-right shunt through a pseudoaneurysm

(Fig. 6). Moreover, 3D-TEE showed the orifice in the

perforated right ventricular basal area with a color jet

through the orifice from the LV to the right ventricle (RV)

(Figs. 7, 8). This indicates that 3D-TEE, to some extent,

may demonstrate complementary anatomical information

without cardiac computerized tomography (CT) or cardiac

Fig. 1 Emergency coronary

angiography revealed triple

vessel disease. The right

coronary artery was regarded as

the culprit artery based on

electrocardiographical and

echocardiographical evaluation

Fig. 2 Poor myocardial

viability observed in the

inferoposterior basal area by

myocardial scintigraphy with99mTc-tetrofosmin

170 J Med Ultrasonics (2012) 39:169–172

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MRI. Finally, we diagnosed the case as inferoposterior

pseudoaneurysm with a left-to-right shunt caused by

myocardial infarction based on the 2D-TTE and the 3D-

TEE findings. These findings were considered sequels of an

inferoposterior myocardial infarction, probably a few

weeks before admission. Because of the past cerebral

infarction, severe stenosis of the basilar artery, low daily

activity of the patient, and agreement with her family, we

decided to treat her conservatively. After 6-month follow-

up, the patient was still doing well.

Discussion

While pseudoaneurysms require urgent surgical resection

because of the likelihood of rupture, true aneurysms can

Fig. 3 Two-dimensional transthoracic two-chamber view of the

pseudoaneurysm. The pseudoaneurysm is located in the inferoposte-

rior basal area. LV left ventricle

Fig. 4 Two-dimensional transesophageal short axis view of the

pseudoaneurysm showed a narrow neck orifice. LV left ventricle

Fig. 5 Pulsed Doppler by 2D-TTE showed turbulent flow at the neck

of a cavity and within the cavity itself. LV left ventricle

Fig. 6 Pulsed Doppler by 2D-TEE indicated left–right shunting

through the pseudoaneurysm. LV left ventricle, RV right ventricle

Fig. 7 Three-dimensional transesophageal echocardiography show-

ing perforation at the right ventricular basal area with pseudoaneu-

rysm formation. RV right ventricle, TV tricuspid valve, IVSinterventricular septum

J Med Ultrasonics (2012) 39:169–172 171

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often be managed medically. This stark difference makes

an accurate diagnosis of post-infarction aneurysm essential.

However, there is still no definitive method to diagnose

pseudoaneurysm [1, 2]. A potential feature proposed for

distinguishing pseudoaneurysms from true aneurysms is

location. For instance, an inferior or posterior location is

suggestive of pseudoaneurysm instead of true aneurysm

[1, 2, 4]. Furthermore, a right coronary culprit and an in-

feroposterior basal aneurysm may indicate pseudoaneu-

rysm rather than true aneurysm in the patient.

In multiple reports, a post-infarction aneurysm with a

narrow orifice has been suggestive of a pseudoaneurysm [5,

6], although Yeo et al. [3] reported that a large number of

post-infarction pseudoaneurysms had a wide neck. In the

present case, 2D-TTE and 2D-TEE showed an aneurysm

with a narrow orifice in the inferoposterior basal area;

therefore, we believed that the post-infarction aneurysm

was a pseudoaneurysm. Loperfido et al. [7] reported that

the presence of turbulent flow by pulsed Doppler at the

neck of a cavity or within the cavity itself suggested a

pseudoaneurysm. Accordingly, in the present case, pulsed

Doppler by 2D-TTE and 2D-TEE showed turbulent flow at

the neck of a cavity and within the cavity itself. As a result,

we diagnosed the pseudoaneurysm by the aforesaid echo-

cardiographical features using only 2D-TTE and 2D-TEE.

However, we could not understand the precise anatomical

relationship between the pseudoaneurysm and both ven-

tricles using only these methods. Therefore, we diagnosed

posterior-septal pseudoaneurysm with a left-to-right shunt

caused by inferior acute myocardial infarction using 3D-

TEE. This approach provided sufficient anatomical evalu-

ation of the orifice in the perforated RV and a color jet

through the orifice from the LV to the RV.

The diagnosis of LV pseudoaneurysm was based on

typical morphologic features shown by each imaging

modality, including angiography [8], CT [9], and MRI [10].

There have been a few cases of LV pseudoaneurysm with a

left-to-right shunt reported, but the efficacy of 3D-TEE to

diagnose pseudoaneurysm with a left-to-right shunt has not

been documented yet [11]. As in the present case, it is

useful to perform 3D-TEE to diagnose a pseudoaneurysm

without cardiac CT or cardiac MRI when the patient cannot

abide by our instructions and control their respiration.

Conclusion

We diagnosed LV pseudoaneurysm with a left-to-right

shunt caused by myocardial infarction using 3D-TEE. Our

approach provided sufficient anatomical evaluation. 3D-

TEE might be an efficient tool to diagnose LV pseudoan-

eurysm with a left-to-right shunt after myocardial

infarction.

Conflict of interest There is no financial conflict on the part of any

of the authors.

References

1. Brown SL, Gropler RJ, Harris KM. Distinguishing left ventricular

aneurysm from pseudoaneurysm. Chest. 1997;111:1403–9.

2. Yeo TC, Malouf JF, Oh JK, Seward JB. Clinical profile and

outcome in 52 patients with cardiac pseudoaneurysm. Ann Intern

Med. 1998;128:299–305.

3. Yeo TC, Malouf JF, Reeder GS, Oh JK. Clinical characteristics

and outcome in postinfarction pseudoaneurysm. Am J Cardiol.

1999;84:592–5, A8.

4. Loop FD, Effler DB, Webster JS, Groves LK. Posterior ventric-

ular aneurysms. Etiologic factors and results of surgical treat-

ment. N Engl J Med. 1973;288:237–9.

5. Gatewood RP Jr, Nanda NC. Differentiation of left ventricular

pseudoaneurysm from true aneurysm with two dimensional

echocardiography. Am J Cardiol. 1980;46:869–70.

6. Catherwood E, Mintz GS, Kotler MN, Parry WR, Segal BL. Two-

dimensional echocardiographic recognition of left ventricular

pseudoaneurysm. Circulation. 1980;62:294–303.

7. Loperfido F, Pennestrı̀ F, Mazzari M, Biasucci LM, Vigna C,

Laurenzi F, Manzoli U. Diagnosis of left ventricular pseudoan-

eurysm by pulsed Doppler echocardiography. Am Heart J.

1985;110:1291–3.

8. Spindola-Franco H, Kronacher N. Pseudoaneurysm of the left

ventricle. Radiographic and angiocardiographic diagnosis. Radi-

ology. 1978;127:29–34.

9. Lipiec P, Chrzanowski Ł, Kasprzak JD. Post-myocardial infarc-

tion biventricular pseudoaneurysm with bidirectional shunt.

Heart. 2010;96:483–4.

10. Konen E, Merchant N, Gutierrez C, Provost Y, Mickleborough L,

Paul NS, Butany J. True versus false left ventricular aneurysm:

differentiation with MR imaging-initial experience. Radiology.

2005;236:65–70.

11. Schreurs M, Herregods MC, Bogaert J, Troost E, Budts W.

Pseudoaneurysm of the left ventricle with moderate left-to-right

shunt. Int J Cardiol. 2008;130:11–3.

Fig. 8 Three-dimensional transesophageal echocardiography demon-

strating a color jet through the orifice of the right ventricle indicating

a left-to-right shunt. RV right ventricle, IVS interventricular septum

172 J Med Ultrasonics (2012) 39:169–172

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