not permitted.
It is not permitted to remove, cover, overlay, obscure, block, or change any copyright notices or terms of use which the Publisher may post on the Article. It is not permitted to frame or use framing techniques to enclose any trademark, logo,
means which may allow access to the Article. The use of all or any part of the Article for any Commercial Use is not permitted. The creation of derivative works from the Article is not permitted. The production of reprints for personal or commercial use is
This document is protected by international copyright laws. No additional reproduction is authorized. It is permitted for personal use to download and save only one file and print only one copy of this Article. It is not permitted to make additional copies
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CORRESPONDENCE
Huge postmyocardial infarction left ventricular
pseudoaneurysm in a patient with previous
self-inflicted thoracic stab wounds
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TO THE EDITOR: A 54-year-old male with a long history of
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smoking and hypercholesterolemia was admitted to our hospital
for a lateral ST- elevation myocardial infarction (Figure 1A) in
Killip class I. His medical history also included a major depres-
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sive disorder with a suicide attempt seven years earlier when
he stabbed himself in the left side of the chest causing multiple
lung lacerations in close proximity of the heart (but without in-
volving of the pericardium) that were repaired by simple sutures
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and surgical staples. Transthoracic echocardiography showed
a an left ventricular ejection fraction of 45% with hypokinesis
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of the left ventricle anterolateral wall. Coronary angiography
performed 7 hours after the onset of chest pain revealed criti-
cal stenosis in left anterior descending artery (LAD) and its first
and second diagonal branches (D1, D2) (Figure 1B) and focal
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critical stenosis of right coronary artery and the second marginal
branch. The patient underwent a single-vessel percutaneous cor-
onary intervention (PCI) with drug eluting stent implantation in
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the LAD and in D2 branch, instead only a plain old balloon angi-
oplasty was done in D1 branch with angiographic success. The
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patient’s coronary care unit course was complicated by pneumo-
nia that was treated with antibiotic therapy and the patient was
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discharged on seventh day in good clinical condition and chest
X-ray showed pneumonia almost completely resolved. At the
follow-up visit scheduled one month following the discharge a
IN
chest X-ray control demonstrated an enlargement over the lower
half of the left-side border of the cardiac silhouette (Figure 1C).
Transthoracic echocardiography revealed a site di rupture in the
high lateral left ventricular, communicating with a large throm-
bus free pseudoaneurysm (Figure 1D) which was confirmed by
M
cardiac computerized tomography (CT) (Figure 2A, B).
The patient was immediately referred for surgical interven-
tion. The intraoperative appearance of the left ventricular pseu-
doaneurysm (LVPs) (Figures 2C, D) showed abundant amounts
of scar tissue around it results of previous surgery to the stab-
bing chest. It was repaired by the endoventricular circular
patch plasty technique where a patch of bovine pericardium
was used, restoring a more normal geometry to the left ventri-
or other proprietary information of the Publisher.
cle. At a 18-month follow-up patient has a favorable outcome.
LVPs is a rare complication of myocardial infarction. Symp-
toms are often non-specific and are sometimes absent which
makes the early diagnosis more challenging especially be-
cause of its susceptibility to breakage may result in a cata-
Vol. 55 - No. 2 THE JOURNAL OF CARDIOVASCULAR SURGERY 303
strophic clinical event.1-2 LVPs is a rupture of the myocardium
that is contained by adherent thrombus, pericardial adhesions
or scar tissue; in particular, its wall lacks of endocardium or
myocardium and is composed of an organized hematoma and
pericardium.2 Pericardial adhesions around LVPs may develop
de novo during the rupture or may be present at the time of
infarction.1-3 It is possible that in our case pleural adhesions
from previous scarring of lung injury may have allowed to
development of LVPs and perhaps preventing its breakage.
Myocardial infarction is the most common cause of false aneu-
rysms of the left ventricle, followed by cardiac surgery, trauma
and, infrequently, infective endocarditis. 2 Recently, it was de-
scribed a case of spontaneous formation of LVPs associated
with alpha1-antitrypsin deficiency.3 Pseudoaneurysm develops
more frequently on posterior, lateral, apical or inferior surface
and rarely on the anterior surface of the left ventricle.1-2 The
most common reported symptoms or conditions are conges-
tive heart failure, chest pain, and dyspnea; otherwise patients
presents asyntomatic, as a incidental detection (as in our case)
and rarely sudden death can be the clinical presentation. 2 Al-
though very difficult, it is important to differentiate false aneu-
rysm from true aneurysm of the left ventricle 4. True aneurysm
contains some original myocardial elements in its walls and is
likely to rupture only in early postinfarction period. It is of-
ten managed medically, surgical repair is indicated only when
there is associated congestive heart failure or arrhythmia, and
it is successful only if there is relative preservation of con-
tractile performance in the non-aneurysmal portion of the left
ventricle. In contrast, LVPs, irrespective of its age, may rupture
and, thus, require urgent surgical repair. Electrocardiographic
and chest X-ray abnormalities are present in >95% of patients;
electrocardiographic changes are usually nonspecific and the
most common chest X-ray finding an enlarged heart, The most
important and difficult findings is the detection or not of con-
tinuity in the myocardium.2,4It can be done with transtoracic
and transesophageus echocardiography, CT scan or Magnetic
resonance imaging.1-2, 4
When the diagnosis is established, surgical correction is usu-
ally mandatory. Timing of the surgery depends on the age of
the myocardial infarction. Surgery is urgently recommended
when a LVPs is discovered within the first 2 to 3 months after
myocardial infarction, because onset of rupture is unpredict-
This document is protected by international copyright laws. No additional reproduction is authorized. It is permitted for personal use to download and save only one file and print only one copy of this Article. It is not permitted to make additional copies
(either sporadically or systematically, either printed or electronic) of the Article for any purpose. It is not permitted to distribute the electronic copy of the article through online internet and/or intranet file sharing systems, electronic mailing or any other
means which may allow access to the Article. The use of all or any part of the Article for any Commercial Use is not permitted. The creation of derivative works from the Article is not permitted. The production of reprints for personal or commercial use is
not permitted. It is not permitted to remove, cover, overlay, obscure, block, or change any copyright notices or terms of use which the Publisher may post on the Article. It is not permitted to frame or use framing techniques to enclose any trademark, logo,
or other proprietary information of the Publisher.

304
LETTERS TO THE EDITOR

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with LVPs (Right ventricle: RV; Left ventricle: LV; Pseudoaneurysm: Ps).
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lateral basal segment of the left ventricle; C, D) intraoperative appearance of lateral LVPs.

THE JOURNAL OF CARDIOVASCULAR SURGERY

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Figure 2.—A, B) Horizontal long axis view (A) and coronal CT image (B) show huge LVPs measuring 7x7x 9 cm (white arrows) of the
Figure 1.—A) Standard 12-lead ECG showing an ST-segment elevation in I and aVL; B) left anterior oblique cranial coronary angiography

of the left cardiac silhouette; D) echocardiographic subcostal window (the only view in which it was visible) showed image compatible
(white asterisks) used in previous lung surgery because of self-inflicted thoracic stabbing; C) Chest X-ray showed a bulge of the lower half

April 2014
shows D1 subocclusion (black arrow) and LAD (gray arrow) and D2 (white arrow) critical stenosis. The view also shows the surgical staples
not permitted. It is not permitted to remove, cover, overlay, obscure, block, or change any copyright notices or terms of use which the Publisher may post on the Article. It is not permitted to frame or use framing techniques to enclose any trademark, logo,
means which may allow access to the Article. The use of all or any part of the Article for any Commercial Use is not permitted. The creation of derivative works from the Article is not permitted. The production of reprints for personal or commercial use is
This document is protected by international copyright laws. No additional reproduction is authorized. It is permitted for personal use to download and save only one file and print only one copy of this Article. It is not permitted to make additional copies
(either sporadically or systematically, either printed or electronic) of the Article for any purpose. It is not permitted to distribute the electronic copy of the article through online internet and/or intranet file sharing systems, electronic mailing or any other

LETTERS TO THE EDITOR

able.5 On the other hand, when diagnosis is made years after
myocardial infarction, the urgency and even the need for oper-
ation is determined by symptoms rather than by risk of rupture.  
However, another meaningful complication of the LVPs is the
ischemic stroke. In view of the fact of the uncertainties about
the natural history of this pathological condition, and the rela-  
tive safety of surgical repair in this subgroup, the decision to
operate should prevail over conservative management in cases  
of large or expanding pseudoaneurysms.5
D. E. MONOPOLI
Department of Cardiology, Modena University Hospital, Modena,  
Italy
demonopoli@gmail.com
References
1. Bryniarski L, Kubinyi A, Ekiert-Kubinyi M, Kawecka-Jaszcz K.
Postinfarction left ventricular pseudoaneurysm with left-to-
right shunt: case report and review of the literature. Int J Car-
diol 2010;139:199-201.
2. Frances C, Romero A, Grady D. Left ventricular pseudoaneu-
rysm. J Am Coll Cardiol 1998;32:557-61
3. Corda L, Vizzardi E, De Cicco G, D’Aloia A, Farina D, Mor-
one M et al. Left ventricular pseudoaneurysm and alpha1-antit-
rypsin enzyme deficiency: Another pathological correlation. Int
J Cardiol. 2010;145:384-6
4. Zoffoli G, Mangino D, Venturini A, Terrini A, Asta A, Zan-
chettin C et al. Diagnosing left ventricular aneurysm from
pseudo-aneurysm: a case report and a review in literature.
2009;4:11.

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P. CIMATO   5. Eren E, Bozbuga N, Toker ME, Keles C, Rabus MB, Yildirim
Department of Cardiac Surgery, Hesperia Hospital, Modena, O et al. Surgical treatment of post-infarction left ventricular
Italy pseudoaneurysm. A two-decade experience. Tex Heart Inst J.

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2007;34:47-51
R. ROSSI
Department of Cardiology, Modena University Hospital, Modena, Conflicts of interest.—The authors certify that there is no conflict of

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Italy interest with any financial organization regarding the material discussed
in the manuscript.
J CAR­DI­O­VASC ­SURG 2014;55:303-5 Epub ahead of print on October 17, 2013.

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or other proprietary information of the Publisher.

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