Review Article


Post-Myocardial Infarction Left Ventricular Pseudoaneurysm: A Meta-Analysis

Authors: Shi-Min Yuan
DOI: https://doi.org/10.37184/lnjpc.2707-3521.4.2
Year: 2022
Volume: 4
Received: Jan 04, 2022
Revised: Jan 22, 2022
Accepted: Jan 24, 2022
Corresponding Auhtor: Shi-Min Yuan (shiminyuan@126.com)
All articles are published under the Creative Commons Attribution License



Abstract

Left ventricular pseudoaneurysm (LVPA) is a rare complication of myocardial infarction. The clinical characteristics and treatment of choice in the current era remain to be elaborated. The present article aims to give an overview of post-infarct LVPA and discuss the management strategy and outcomes. The study was based on comprehensive retrieval of literature of the recent 10 years. Myocardial infarctions as the underlying causes of LVPAs were mostly acute myocardial infarctions. The mean time for LVPA formation was 51.7 months after myocardial infarction. Postoperative and follow-up ejection fraction values were significantly higher than preoperative. In the interventional group patients, the oversize ratio of patients in whom devices remained in position was a little larger than that of those with a migrated one, but lack of a statistical significance (1.32±0.25 vs. 1.25±0.21, p=0.707). The mortality rate was significantly higher in the conservative group than in the surgical and interventional groups. Post-infarct LVPAs are curable to surgical aneurysmectomy and left ventricular reconstruction, thereby avoiding unexpected LVPA ruptures and other fatal complications. Elderly patients and patients at a high operative risk may resort to interventional therapy. The conservatively treated patients inevitably carry a considerable risk of death. An oversize ration of >1.3 might be a reference value for preventing device migration in the interventional group patients.

Key Words: Aneurysm, false, heart ventricles, cardiac surgical procedures.


INTRODUCTION

Left ventricular pseudoaneurysm (LVPA) is a rare complication of myocardial infarction, cardiovascular surgery, trauma, or infection, with myocardial infarction being the most common etiology [1]. LVPA develops in 0.1% of patients following myocardial infarction [2]. LVPAs can be arising from the free wall, left ventricular outflow tract and mitral-aortic intervalvular fibrosa. The formation time of LVPA with various etiologies varies from 1 day [3] to 25 years [4]. According to the formation time, LVPAs can be divided into acute (onset <2 weeks) and chronic (onset >2 weeks) [5].

There are two types of concurrent LVPAs and true aneurysms of the left ventricle: mixed (conjunct true and false) and false-true superimposed [6]. Moreover, daughter aneurysms arising from the LVPA [6], multiple [7], multi-loculated [5, 8], apical tunnel-shaped [9] and recurrent LVPAs [10] have also been described. The diversity and heterogeneity of the pathological forms of LVPAs make diagnosis difficult and lead to error or delay.

LVPA is formed secondary to an incomplete rupture of the left ventricular wall contained by the pericardium [11]. Davutoglu [5] deliberately narrated the differences between false and true aneurysms: 1) The orifice to cavity ratio was 0.25–0.50 for false, and 0.90–1.0 for true aneurysms; 2) An inferior or posterior location

*Corresponding author: Shi-Min Yuan, Department of Cardiothoracic Surgery, The First Hospital of Putian, Teaching Hospital, Fujian Medical University, 389 Longdejing Street, Chengxiang District, Putian 351100, Fujian Province, People’s Republic of China; Email: shiminyuan@126.com

Received: January 04, 2022; Revised: January 22, 2022; Accepted: January 24, 2022 DOI: https://doi.org/10.37184/lnjpc.2707-3521.4.2


is suggestive of pseudoaneurysm; and 3) The true posterior aneurysm is often associated with extensive infarction and the resultant severe mitral regurgitation, which are seldom seen in false aneurysms.

Post-infarct LVPAs commonly occur in patients with transmural myocardial infarction, where the whole thickness of the myocardium is involved. They are commonly located in the inferior or posterolateral walls [12]. When a pseudoaneurysm develops, serious complications, such as angina, heart failure, arrhythmias, thrombus with embolization and fatal rupture may occur [12]. Moreover, the differential diagnosis between LVPA and true aneurysm of the left ventricle is important, as the former often presents with heart failure and even cardiogenic shock and is more likely to rupture compared to true aneurysm [13]. Thus, the diagnosis and treatment of LVPA are still compelling and challenging. The present article aims to give an overview of post-infarct LVPA and discuss the management strategy and outcomes.

METHODS

Comprehensive retrieval of pertinent literature in the PubMed database, Google Scholar and “Baidu” Scholar was carried out for articles published between 2011 and 2021. The retrieval terms included “myocardial infarction”, “post-infarction”, “left ventricular pseudoaneurysm”, “aneurysmectomy”, “left ventricular reconstruction”, “percutaneous closure”, “cardiopulmonary bypass” and “cardiac surgical procedures”. The inclusion criteria were clinical research, case series and case reports of left ventricular pseudoaneurysm following myocardial infarction. The exclusion criteria were


Publications identified and screened

(n=219)

Excluded (n=72)

Non-myocardial infarction LVPA (n=34)

* LVPA of past CABG/MVR/AVR/TAVR (n=16)

* LVPA without a cause of AMI (n=10)

* Post-traumatic LVPA (n=4)

* Systemic lupus erythematosus -related LVPA (n=1)

*Infective endocarditis caused LVPA (n=1)

* LVPA due to Dacron patch detachment (n=1)

* Primary effusion lymphoma as a cause of LVPA (n=1) Mechanical complications of AMI (n=13)

* Post-infarct free wall rupture (n=8)

* Post-infarct ventricular septal rupture (n=2)

*Mechanical complications of AMI (n=3)

Other abnormal structures of the left ventricle (n=5)

* Left ventricular thrombosis (n=2)

* Left ventricular pouch (n=1)

* Left ventricular clefts (n=1)

*Congenital “bifid” left ventricular apex (n=1) Pseudoaneurysm of other structures (n=7)

* LVPA of transplanted heart (n=2)

* Right ventricular/aortic/coronary/saphenous venousgraft/intraseptal pseudoaneurysm (n=5)

Left ventricular true aneurysm (n=5)

Delayed myocardial infarction presentations (n=1) Prevalence of LVPA in pericardial effusion patients (n=1) Lack of patient information (n=5)

Complete duplicate publication (n=1)

Publications of LVPA due to myocardial

infarction (n=147, 169 pts)

Excluded (n=12, 13 pts) Treatment of LVPA not mentioned (n=4) Patient deteriorated and died soon (n=3)

Patient refused operation and lost follow-up (n=2) Patient refused operation and died soon (n=1) Patient died while waiting for surgery (n=1)

LVPA deemed follow-up (n=1) LVPA diagnosed by autopsy (n=1)

Publications included in the review (n=135, 156 pts)

Location

n (%)

Inferior [15–17, 27, 30, 34, 36, 37, 42–44, 46, 47, 50, 52,

54, 55, 58–60, 62, 64, 66, 69, 71, 72, 75–77, 83, 84, 89,

90, 92, 96, 99, 101, 108, 109, 111, 114, 115, 123, 125, 126,

130, 139, 141]

57 (47.5)

Anterior [14, 24, 25, 29, 41, 47, 48, 56, 65, 67, 74, 93, 100,

105, 106, 112, 120, 127, 131, 133, 135, 138, 140]

23 (19.2)

Lateral [35, 39, 81, 94, 109, 113, 118, 145]

10 (8.3)

Non-ST elevated [26, 28, 86, 102, 107, 143, 144]

7 (5.8)

Inferolateral [21, 33, 61, 98, 128]

5 (4.2)

Inferoposterior/posteroinferior [68, 85, 89]

5 (4.2)

Posterior [63, 87, 89, 119]

4 (3.3)

Anterolateral [31, 45, 129]

3 (2.5)

Anteroinferior (apical)/inferoanterior [18, 32]

2 (1.7)

Anteroseptal [97]

1 (0.8)

Posterolateral [89]

1 (0.8)

Basal inferior & inferolateral [116]

1 (0.8)

Inferior, lateral & posterior [40]

1 (0.8)

Table 1: The locations of myocardial infarctions in 120 patients.

Fig. (1): A flow chart of literature inclusion and exclusion. AMI: acute myocardial infarction; AVR: aortic valve replacement; CABG: coronary artery bypass grafting; LVPA: left ventricular pseudoaneurysm; MVR: mitral valve replacement; pts: patients; SLE: systemic lupus erythematosus; TAVR: Transcatheter aortic valve replacement.

articles describing: LVPA with a cause of other than myocardial infarction (n=34), mechanical complications of acute myocardial infarction (n=13), pseudoaneurysm of other structures than of the left ventricle (n=7), left ventricular true aneurysm (n=5), other abnormal structures of the left ventricle (n=5), delayed myocardial infarction presentations (n=1), the prevalence of LVPA in pericardial effusion patients (n=1), lack of patient information (n=5) and complete duplicate publication (n=1). A total of 72 articles were excluded and 147 articles with 169 patients were retained. Nevertheless, in 13 of the 147 recruited articles, 13 cases of patients with LVPAs were not treated due to patient’s sudden death or patient’s refusal for surgical treatment, and therefore 12 of these 13 articles were excluded (one of the articles was retained as another case reported in it was eligible for the inclusion criteria). Finally, 135 articles with 156 patients were recruited into this study (Fig. 1).

IBM SPSS statistics 22 software was used for the statistical analysis. The measurement data were expressed in mean±standard deviation and compared with independent samples t-test. Categorical variables were compared by Fisher’s exact test with continuity correction. p<0.05 was regarded statistically significant.

RESULTS

The recruited 135 articles [4, 8, 14–146] included 3 (2.2%) retrospective studies [8, 89, 109], 4 (3.0%) case series [23, 47, 57, 107] and 128 (94.8%) case reports [4, 14–22, 24–46, 48–56, 58–106, 108, 110–146] with a total of 156 patients all of whom were diagnosed with post-infarct LVPA. Gender of two patients was not given. In the remaining 154 patients, there were 114 (74.0%) male and 40 (26.0%) female patients (χ2=71.1, p<0.001) with a male-to-female ratio of 2.9:1. Their mean age was 64.2±11.8 (range, 28–90; median, 64.5) years (n=156).Myocardial infarctions as the underlying causes of LVPAs were mostly acute myocardial infarctions, whereas there were 7 (4.5%) subacute and 7 (4.5%) chronic myocardial infarctions. In addition, there were 2 silent myocardial infarctions [80, 146] and 1 unrecognized myocardial infarction [4]. The locations of myocardial infarctions as the underlying causes of LVPAs were shown in Table 1.

A previous surgical or interventional history was reported in 62 (39.7%) patients: percutaneous coronary intervention with or without stenting was reported in 31 (50%) patients, a previous heart operation (coronary artery bypass grafting, valve replacement/repair, free wall rupture/ventricular septal rupture repair, or left ventricular aneurysmectomy) was performed in 27 (43.5%) patients, and both percutaneous coronary intervention and heart operation in 4 (6.5%) patient. The time interval from myocardial infarction to LVPA formation was 51.7±24.0 (range, 0–276; median, 4)

Table 2: 200 symptoms in 121 symptomatic patients.

Clincial Presentation

n (%)

Chest pain [14–16, 21, 23, 28, 29, 34, 37, 40, 46–48, 51, 56,

60, 65, 69, 73, 81, 87, 89, 95, 103, 106, 108, 109, 111, 114,

117, 120, 122, 126, 136–138, 143, 144]

46 (23)

Dyspnea [15, 18, 22–25, 27, 30, 32–34, 42–45, 51, 53, 55,

58, 62, 64, 66, 71, 78, 80, 81, 85, 87–89, 99, 111, 117, 119,

121, 124, 126, 128, 138, 145]

40 (20)

Heart failure [8, 32, 34, 39, 47–49, 54, 68, 79, 80, 82, 84, 87,

99, 100, 109, 116, 123, 125, 130, 135, 138, 141]

34 (17)

Shortness of breath [20, 23, 26, 28, 29, 35, 37, 53, 74, 75,

102, 122, 131, 132]

14 (7)

Shock [15, 16, 38, 45, 49, 53, 60, 72, 81, 136]

10 (5)

Syncope [28, 31, 40, 80, 81, 89, 90, 129, 142]

9 (4.5)

Cough [46, 53, 71, 89]

4 (2)

Orthopnea [20, 55, 137, 119]

4 (2)

Anasarca/edema [53, 54, 91, 132]

4 (2)

Fatigue [20, 42, 88]

3 (1.5)


Clincial Presentation

n (%)

Anorexia [34, 91]

2 (1)

Chest discomfort [100, 121]

2 (1)

Nausea [34, 144]

2 (1)

Palpitations [18, 74]

2 (1)

Fatigue/tiredness [34, 53]

2 (1)

Weakness [30, 53]

2 (1)

Weight loss [58, 80]

2 (1)

Abdominal pain [42]

1 (0.5)

Agitated [81]

1 (0.5)

Asthenia [66]

1 (0.5)

Chest distress [25]

1 (0.5)

Confusion [80]

1 (0.5)

Disorientation [117]

1 (0.5)

Epigastric discomfort [112]

1 (0.5)

Epigastric pain [89]

1 (0.5)

Hemiparesis [132]

1 (0.5)

Hypotensive [53]

1 (0.5)

Interscapular pain [78]

1 (0.5)

Lightheadedness [91]

1 (0.5)

New systolic murmur [19]

1 (0.5)

Profuse sweating [81]

1 (0.5)

Shoulder pain [92]

1 (0.5)

Stridorous breathing [104]

1 (0.5)

Transient ischemic attack [132]

1 (0.5)

Verbal aphasia [72]

1 (0.5)

Table 4: The dimensions of the LVPAs.

Dimension

Mean±SD

Range

Median

n

Longth, mm

71.9±29.4

19-150

70

85

Width, mm

55.5±23.9

5-110

52

70

Hight, mm

47.7±14.4

20-74

47.5

22

Neck, mm

23.7±14.6

3.8-65

21

59

Neck- to - maxi- mum diameter of pseudoaneurysm ratio

0.39±0.22

0.03-1.02

0.36

46


months (n=95).

On current admission, clinical presentations were described for 135 patients: 14 (10.4%) patients were

asymptomatic, while 121 (89.6%) patients were symptomatic with a total of 200 symptoms (Table 2).

Table 3: The 258 diagnostic modalities for the diagnosis of LVPAs in 139 patients.

Diagnostic Modality

n (%)

Transthoracic echocardiography [4, 8, 15, 17–19, 21,

23, 25, 27-39, 41, 42, 44–48, 50–56, 60, 62, 63, 65–68,

70–76, 78–86, 88–92, 95–105, 107–115, 117, 119, 121–

129, 131, 133–138, 140–146]

126 (44.2)

Computed tomography [20, 25, 35, 37, 40, 49, 57, 59,

63–65, 72, 76, 77, 79, 80, 87–92, 94, 99, 100, 103–105,

108, 111, 112, 114, 118, 119, 122, 124, 132, 133, 135,

142, 143, 146]

47 (16.5)

Magnetic resonance imaging [4, 17, 20, 28, 30, 35, 36,

39, 40, 46, 48, 53–55, 59, 61, 66, 68, 82, 89, 98, 101,

106, 110, 112, 113, 115, 128, 134, 138, 139, 146]

34 (11.9)

Left ventriculography [14, 21, 22, 31, 43, 62, 68, 70, 90,

95, 102, 109, 118, 121, 128, 143]

25 (8.8)

Transesophogeal echocardiography [26, 29, 45, 68,

109, 124]

18 (6.3)

Chest X-ray [29, 62, 63, 80, 103, 105, 111, 114, 146]

9 (3.2)

Three-dimensional transesophogeal echocardiography [17, 19, 26, 70, 73, 85, 88, 129]

8 (2.8)

Computed tomographic angiography [8, 14–16, 55, 106,

124]

8 (2.8)

Cardiac catheterization [64, 77, 79]

3 (1.1)

Coronary angiography [31, 66, 69]

3 (1.1)

Contrast echocardiography [31, 82]

2 (0.7)

Ultrasonography [49]

1 (0.4)

Myocardial perfusion imaging [112]

1 (0.4)


The 258 diagnostic modalities for the diagnosis of LVPAs in 139 patients was shown in Table 3. It revealed a correct diagnostic rate of 99.2% (256/258). The diagnosis of LVPA was missed by computed tomography in 2 patients [73, 146], with a false-negative rate of 4.3% of computed tomography.

The LVPAs recurred in 6 (6/156, 3.8%) patients: 5 (83.3%)

patients recurred once [31, 65, 77, 78, 143] and 1 (16.7%) patient with a ruptured LVPA had twice recurrences and the LVPA ruptured at each recurrence [21]. Moreover, one patient who underwent percutaneous closure of LVPA had twice device migrations [8]. Therefore, there were 166 LVPAs in the 156 patients. The dimensions of the LVPAs were listed in Table 4.

In 9 (5.4%, 9/166) LVPAs of 9 (9/156, 5.8%) patients, a wide neck rather than a narrow neck was present. The necks of these 9 LVPAs measured 20–65 mm with a neck-to-cavity ratio of 0.54–1.02. However, they were still diagnosed as LVPA rather than a true aneurysm of the left ventricle. In 3 LVPAs of 3 patients, there were 2 orifices for each. In 2 of the above 3 patients, the second orifice communicated with the right ventricle. In another 2 patients, the LVPAs communicated with the right ventricle. Mural thrombus was noted in 44 (26.5%) patients. Pericardial effusions were present in 25 (15.1%) patients. Mitral valve regurgitation was present in 30 (19.2%) patients (mild in 7 (23.3%), mild to moderate in 4 (13.3%) (2 of them had mild aortic regurgitation), moderate in 10 (33.3%) (1 of them had concurrent mild to moderate tricuspid regurgitation), severe in 7 (23.3%), and unspecified degree in 2 (6.7%) patients). Besides, moderate tricuspid regurgitation was noted in 1 patient. In 5 (3.2%) patients, LVPAs ruptured and in one of these patients, LVPA ruptured 3 times. A concomittent true aneurysm was found in 7 (4.5%) patients: 2 (28.6%) were mixed and 5 (71.4%) were superimposed. Other associated conditions were ventricular septal rupture in 11 (7.1%), free wall rupture in 3 (1.9%), papillary muscle

rupture in 1 (0.6%), tamponade in 5 (3.2%), infective

endocarditis in 2 (1.3%), colon carcinoma in 2 (1.3%), dilatative alcoholic cardiomyopathy in 1 (0.6%) and symmetrical peripheral gangrene in 1 (0.6%) case.

Left ventricular ejection fraction was reported for 62 patients. It was described as normal in 2 patients [97, 143], and preserved in 1 patient [62]. The remaining 59 patients had an ejection fraction of 33.9±11.2 (range, 11-63; median, 32)%. The locations of 98 LVPAs were



Table 5: Locations of 100 LVPAs.

Locations

n (%)

Apical [4, 25, 26, 31, 41, 47–49, 66, 78, 104, 106, 127,

129, 131, 135, 140]

17 (17)

Inferior [22, 32, 46, 47, 58, 69, 72, 77, 79, 90, 92, 115, 125]

13 (13)

Lateral [27, 33, 39, 89, 93, 94, 112, 118]

11 (11)

Posterior [23, 30, 70, 87–89, 95, 102, 107, 126]

11 (11)

Inferolateral [20, 40, 55, 82, 83, 101, 111, 114]

8 (8)

Anterior [19, 99, 100, 105, 133, 142]

6 (6)

Anteroapical [8, 53]

5 (5)

Inferoposterior [42, 44, 76, 85, 130]

5 (5)

Anterolateral [74, 80, 124]

3 (3)

Basal inferior [16, 54, 71]

3 (3)

Basal inferolateral [15, 84, 139]

3 (3)

Apicolateral [138, 145]

2 (2)

Inferior, inferolateral [17, 123]

2 (2)

Inferoseptal [36, 96]

2 (2)

Lateral posterior/posterior lateral [122, 136]

2 (2)

Apical, mid-anterolateral, mid-inferolateral [98]

1 (1)

Inferoapical [50]

1 (1)

Infero-basal [21]

1 (1)

Inferolateral, anterolateral [108]

1 (1)

Inferoposterolateral [116]

1 (1)

Lateral, inferior [37]

1 (1)

Mid posterior [23]

1 (1)

described with apical LVPAs being the most common ( Table 5).

Patients could be divided into 3 groups according to treatment methods: surgical 116 (69.9%) cases, interventional 17 (10.2%) cases and conservative

33 (19.9%) cases. Patient age was much younger in surgical than that of the other two group patients (Fig. 2).

Surgical operation of LVPA was performed in 116 cases including 6 recurrences. Twenty (16.9%) cases were operated on an urgent basis. The surgical indications were LVPA enlargement [47], LVPA with a potential to rupture [69, 48, 119], a potential for complications [48], and limited surgical field exposure owing to the previous cardiac operation with videoscopic guidance becoming an only choice [59]. The operational parameters of open surgery were shown in Table 6.

Fig. (2): Patient age was much younger in surgical than that of the other two group patients.


Fig. (3): Postoperative and follow-up ejection fraction values were

significantly higher than preoperative value.

Table 6: The operational parameters of open surgery.

Operational Parameter

n (%)/Mean±SD (range; median)

Surgical approach (n=12)

Sternotomy [22, 45, 53, 57, 68, 74, 86,

91, 127]

8 (66.7)

Thoracotomy [57, 76, 79]

3 (25)

Minithoracotomy (at the right 4th intercostal space for videoscopy) [59]

1 (8.3)

Cardiopulmonary bypass (n=33)

Standard cardiopulmonary bypass [22, 45, 53, 55, 74, 91, 100, 109, 118, 127]

18 (54.5)

Normothermic cardiopulmonary bypass with on-pump beating-heart [53, 74]

2 (6.1)

Femorofemoral byapss [49, 57, 59, 65,

68, 76, 79, 86, 92, 109]

13 (39.4)

Cardiopulmonary bypass time

Cardiopulmonary bypass time (min)

(n=8)

179.3±91.3

(103–386; 165)

Crossclamp time (min) (n=6)

140.5±73.4 (74–278; 131)

Surgical procedure

Aneurysmectomy [16, 17, 20, 22, 26,

29, 31, 33, 40, 42–51, 53–55, 57–59,

61–63, 68–71, 74–76, 78, 79, 82, 89,

91, 94, 95, 99, 102, 104, 105, 110, 113,

115, 118, 121–123, 126, 127, 129, 136,

145]

59 (50.9)

Left ventricular reconstruction [16, 17,

20, 21, 23, 26, 28, 29, 31, 33]

96 (82.8)

Coronary artery bypass grafting [35, 36,

38, 40, 42, 43, 45–47, 49–51, 53–55,

57–60, 62–65, 67–69, 71, 73–79, 82,

86, 89, 91, 92, 94, 95, 98, 99, 102, 104–

107, 109, 110, 113, 115, 116, 118–123,

126–129, 133, 135, 136, 138, 141–146]

34 (29.3)

Valve operation

10 (8.6)

Mitral valve replacement [44, 50, 58,

59, 91, 109]

7 (70)

Mitral valve annuloplasty [31, 70]

2 (20)

Aortic and mitral valve replacements [109]

1 (10)

Ventricular septal rupture repair [36, 45,78, 109, 121]

8 (6.9)

Free wall rupture repair [33]

1 (0.9)

Heart transplantation [66]

1 (0.9)

Left ventricular aneurysm resection [31]

1 (0.9)

MAZE procedure [102]

1 (0.9)

Chest wall reconstruction [65]

1 (0.9)

Right ventricular assist device [53]

1 (0.9)

Cardioverter-defibrillator implantation

[77]

1 (0.9)



Table 7: Patch repair materials.

Patch Repair Material

n (%)

Bovine pericardium [16, 22, 26, 35, 50, 54, 64, 77, 86, 94,

100, 104, 116, 120, 128, 138]

16 (23.3)

Dacron [33, 46, 68, 69, 70, 76, 78, 95, 105, 107, 109,

118, 141]

14 (20.3)

Patch, unspecified [20, 43, 47, 49, 58, 62, 82, 98, 99, 109,

143]

11 (15.9)

Polytetrafluroethylene (PTFE) [51, 63, 102, 135, 136]

5 (7.2)

Autologous pericardium [109, 126]

3 (4.3)

Gore-Tex [109]

3 (4.3)

Pericardial patch [23, 31, 113]

3 (4.3)

Biological patch [65]

2 (2.9)

Bovine pericardial-Dacron (double) [45, 91]

2 (2.9)

Dacron-equine pericardium [57]

2 (2.9)

2 Bovine pericardia with polyester patch between [40]

1 (1.4)

Bovine-paricardiium (double) [79]

1 (1.4)

Dacron (double) [109]

1 (1.4)

Dacron-bovine pericardium [127]

1 (1.4)

Expanded polytetrafluoroethylene [55]

1 (1.4)

Equine pericardium, Teflon-backed [59]

1 (1.4)

Patch (double) [92]

1 (1.4)

Polyester tube graft tailored patch [110]

1 (1.4)

Techniques for left ventricular reconstruction were described for 82 cases: patch repair in 69 (84.1%) and primary suture in 13 (15.9%) cases. Patch repair materials were listed in Table 7.

Postoperative and follow-up ejection fraction values were significantly higher than preoperative values (Fig. 3).

The surgical patients were on a follow-up of 21.4±47.6 (range, 0.8-288; median 12) months (n=41). Of the total 98 patients with a primary LVPA whose prognoses were indicated, 83 (84.7%) recovered, 6 (6.1%) recurred, and 9 (9.2%) died. The recurrence time of LVPAs was 35.0±51.5 (range, 0.3-120; median, 6) months (n=5).

Interventional therapy was conducted in 17 cases, including 1 patient developing twice device migrations [8] and 1 patient who recurred twice after the initial surgical treatment [21].

The indications for interventional therapy were: high risk of mortality, severe LV dysfunction and heart failure [84], comorbid conditions, previous myocardial infarction with reduced left ventricle function [93], redo operation [93, 97, 130, 131], advanced age [131], patient’s refusal of surgical treatment [125] and an EuroScore estimated mortality of 15% [130].

An approach was given for 12 cases: via a retrograde approach in 8 (66.7%) (transfemoral in 5 (one patients with failed retrograde left femoral arterial access and converting to antegrade right femoral vein), transaxillary in 1 [84], retrograde unspecified in 2 [8, 21]), retrograde/

transapical in 2 (16.7%) [8], transapical + transseptal in 1 (8.3%) [8] and transapical via a mini anterolateral thoracotomy in 1 (8.3%) patient [130]. In all 18 occluders were used in 17 patients: 11 (61.1%) Amplazter Septal Occluders, 2 (11.1%) Amplazter

Muscular VSD Occluders [8, 21], 2 (11.1%) muscular ventricular septal defect occluders in 1 patient for 2 shunts [131], 1 (5.6%) Amplazter ASD [14], 1 (5.6%) RTM muscular VSD device [130] and 1 (5.6%) unspecified Amplazter device [134].

The overall oversize ratio of the devices was 1.28±0.22 (range, 1–1.6; median, 1.4) (n=10). The oversize ratio of the patients in whom devices remained in position was a little larger than that of those with a migrated one, but lack of a statistical significance (1.32±0.25 vs. 1.25±0.21, p=0.707).

They were on a follow-up of 13.3±16.4 (range, 1–60; median 6) months (n=12). Their outcomes were: recovered 14 (82.4%), complicated 2 (11.8%) and died 1 (5.9%).

Conservative treatment of LVPAs was applied in 33 cases. However, 3 of them had an alternative surgical/ interventional procedure: surgical free wall rupture repair [143], surgical ventricular septal rupture repair [24] and percutaneous ventricular septal rupture closure (with an Amplatzer Septal Occluder) [15] in 1 patient each. The left ventricular ejection fraction of the conservatively treated patients were 33.8±14.0 (range, 10–63; median, 32.5)% (n=16) before treatment.

The indications for an interventional procedure were advanced age [34, 81, 90], being deemed too high risk, a calcific wall surrounding the pseudoaneurysmatic formation [37], previous cerebral infarction [85], patient decline of surgical treatment, patient’s poor prognosis [25], patient’s choice [96, 114], severe left ventricular dysfunction and multiple comorbidities [19], small LVPA [24, 143], lower risk of pseudoaneurysm rupture with limited estimated patient survival due to concurrent metastatic colonic cancer [4] and “the ‘petrous’ consistency which made resection impossible” [108].

The conservatively treated patients were on a follow-up of 15.4±17.2 (range, 1-61; median, 17) months (n=13). The ejection fraction after treatment was not reported in each patient. Outcomes of 7 patients were not described. In the remaining 26 patients, 12 (46.2%) were stable, 2 (7.7%) were improved, 1 (3.8%) was complicated with myocardial infarction, 1 (3.8%) recurred, and 10 (38.5%) died.

In overall, patients were on a follow-up of 18.7±38.8 (range, 0.8-288; median, 8.8) months (n=66). Outcomes of 141 cases were described: 99 (70.2%) recovered, 2 (1.4%) were improved, 3 (2.1%) were complicated, 7 (5.0%) recurred (including a second recurrence), 12 (8.5%) were stable, and 18 (12.8%) died (all were early deaths). In addition, all 8 recurrent cases (including twice chances of device migrations) warranted reinterventions with a reintervention rate of 4.8% (8/166). The mortality rate was significantly higher in the conservative group than in the surgical and interventional groups (38.5% vs. 9.2% vs. 5.9%, χ2=15.6, p<0.001).

DISCUSSION

Diagnosis

The diagnosis of LVPA should be considered in patients with poor responses to medical treatment or those with refractory heart failure. A physical examination may reveal to-and-fro heart murmurs [147]. Left ventricular angiography appears promising in revealing posterolateral LVPA; however, it is invasive. Nowadays, echocardiography, cardiac magnetic resonance imaging and computed tomography are alternative noninvasive diagnostic techniques with excellent visualization of LVPA [147]. By echocardiography, the entrance of the LVPA could be clearly visualized [148]. Computed tomography may sometimes not tell false from the true aneurysm, and probably inaccurately determine the location of the origin of LVPA [149]. Magnetic resonance imaging distinguishes among pericardium, thrombus and myocardium, displays disruption of the epicardial fat layer of the LVPAs, but is unable to discriminate mural thrombus from the LVPA walls thus leading to an inaccurate measurement of the size of LVPA [5].

Clinically, true aneurysms are often associated with ventricular tachycardia and (or) heart block and even sudden cardiac death [150], but this is uncommon in cases with an LVPA. Echocardiography may be helpful in the differentiation between true and false aneurysms usually by showing a narrow neck in LVPAs, equivalent neck to the cavity in true aneurysms [151]. Although transthoracic echocardiography is commonly used for the diagnosis of LVPA, transesophageal echocardiography seems superior to it in the evaluation of LVPA [53]. Histopathological examination of the excised ventricular wall helps to confirm the diagnosis [8].

Treatment

LVPAs <3 cm are usually stable [152], and are conservatively managed with acetylsalicylic acid, nitrates, angiotensin-converting enzyme inhibitor and β-blockers [153], and anticoagulants, etc. [154]. Patients with an LVPA with an increased size despite regular conservative treatment warrant interventional management [155].

Some authors proposed that due to the high propensity of LVPA rupture, patients with an LVPA are indicated for a surgical repair upon diagnosis is made [156]. In certain cases, LVPA represents a fatal complication of myocardial infarction and it necessitates an urgent operation [53]. However, whether a chronic LVPA needs emergency surgery is not clear [147].

In the surgical treatment of LVPAs, median sternotomy facilitates the establishment of cardiopulmonary bypass and cardioplegic arrest easily and securely. Nevertheless, exposure of a posterolateral LVPA via a median sternotomy seems to be of some difficulties


in comparison with a left thoracotomy due to the deep location of LVPA [57]. On a few occasions, an anterior left thoracotomy [10, 157], a right lateral position, or an anterolateral mini-thoracotomy [9] was applied depending on the patient situation.

Prevention of LVPA rupture was the primary goal of repair [8]. Garrido et al. [158] emphasized that the surgical technique of choice should follow the principle of protecting the left ventricular geometry. The popular technique of LVPA repair was the endoventricular patch plasty technique (“Dor” procedure) [159]. Mitral regurgitation in cases of posterior LVPAs may be relieved after resection of the LVPA and does not need a valve replacement.

In the past, conservative treatment can be considered in patients who carry a high risk for operation [160]. Nowadays, percutaneous interventional therapy offers an alternative therapeutic possibility for such patients. The size of the devices should be larger [8] or at least equal to the neck of the orifice of LVPA. This suggestion was supported by the present study, where an oversize ratio of ≥1 was found.

Prognosis

Patients with an LVPA have high morbidity and risk of spontaneous rupture and sudden death [161]. Despite the high mortality rates for patients of LVPA without receiving a surgical operation, prolonged survival in some conservative patients was also reported [1]. The rupture rate was reported to occur in 30–45% of the patients [162]. Whereas, the present study demonstrated a much lower rupture rate of only 3.2%. This might be explained by the late formation of LVPAs at a mean of 51.7 months after myocardial infarction. Furthermore, death (9%), hemorrhage (7%) and arrhythmia (6%) were reported to be the more common adverse events of LVPAs. The recurrence rate of LVPA after surgical repair was 5% [1]. Postoperative mortality rates ranged between 7–29% [3]. The recurrence and mortality rates of the present study were similar to what have been reported in the literature. In addition, there was a report describing a self-cured LVPA [163].

This study revealed that the mortality rate of the surgical group patients was 9.2%, which was closer to but a bit better than the reported mortality of surgical patients 12.5% in 2006 [164]. The interventional therapy of LVPAs has not yet been reported in a large number of cases until present, and the overall prognosis of patients cannot be concluded with certainty. But recent reports showed good outcomes in small series of patients [165]. This study also showed that the surgical patients were much younger than the other two group patients. This hinted aged patients carrying high risks of operation resorted to interventional and conservative treatments. The left ventricular ejection fraction improved significantly after surgical aneurysmectomy and during follow-up, thus the operative effect for the treatment of LVPAs was in full proof.

Limitations still exist owing to the pertinent missing data from the reports. The post-infarct left ventricular ejection fractions in the interventional and conservative group patients were not available for comparisons and evaluations. Moreover, the predominance of transmural myocardial infarction, the influence of myocardial infarction on the functions of the papillary muscles and the mitral valve and subsequent treatment of choice of the mitral valve disorders, and the cut-off value of the oversize ratio indicating a possible device migration were not evaluated. These aspects need to be supplemented and assessed on the basis of more perfect data in the future.

CONCLUSION

Post-infarct LVPAs are curable to surgical aneurysmectomy and left ventricular reconstruction, thereby avoiding unexpected ruptures and other fatal complications. Aged and high-risk patients may resort to interventional therapy. The conservatively treated patients inevitably carry a considerable risk of death. An oversize ration of >1.3 might be a reference value for preventing device migration in the interventional group patients.

FUNDING

None.

CONFLICT OF INTEREST

The author declares no conflict of interest.

ACKNOWLEDGEMENTS

Declared none.

REFERENCES

1. Chourmouzi D, Karagounis L, Ioannidis S, Drevelegas A. Submitral left ventricular pseudoaneurysm after mitral valve replacement. Eur J Cardiothorac Surg 2009; 35(4): 728.

2. Faiza Z, Lee LS. Left Ventricular False Aneurysm. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing 2021.

3. Moreno R, Zamorano JL, Almería C, Rodrigo JL, Villate A, Serra V, et al. Usefulness of contrast agents in the diagnosis of left ventricular pseudoaneurysm after acute myocardial infarction. Eur J Echocardiogr 2002; 3(2): 111-6.

4. Sehmi JS, Dungu J, Davies SW, Khattar R, Senior R, Chahal

N. Unsuspected large left ventricular pseudoaneurysm: rapid bedside diagnosis by contrast-enhanced echocardiography. Oxf Med Case Reports 2015; 2015(11): 358-9.

5. Davutoglu V. Massive left ventricular aneurysm or unruptured pseudoaneurysm? Circulation 2004; 110(12): e317.

6. Mackenzie JW, Lemole GM. Pseudoaneurysm of the left ventricle. Tex Heart Inst J 1994; 21(4): 296-301.

7. Kothari J, Hinduja M, Baria K, Patel R. Surgical repair of multiple congenital left ventricular aneurysms with rupture into left atrium. J Card Surg 2016; 31(9): 601-3.

8. Dudiy Y, Jelnin V, Einhorn BN, Kronzon I, Cohen HA, Ruiz CE. Percutaneous closure of left ventricular pseudoaneurysm. Circ Cardiovasc Interv 2011; 4(4): 322-6.

9. Muraru D, Napodano M, Beltrame V, Badano LP. Left ventricular pseudoaneurysm after transapical aortic valve-in-valve implantation: use of transthoracic 3D echocardiography for guiding therapeutic approach. Eur Heart J 2016; 37(15): 1255. .


10. Sansone F, Ceresa F, Patanè F. Left ventricular pseudoaneurysm after left ventricular remodeling: port access approach. Innovations (Phila) 2014; 9(1): 66-8.

11. Keller H, Genth K, Schlauch D, Saggau W, Stegaru B, Buss J, et al. Subacute left ventricular free wall rupture with false aneurysm visualized by two-dimensional echocardiography. Am Heart J 1987; 114(1 Pt 1): 170-2.

12. Acharya D, Nagaraj H, Misra VK. Transcatheter closure of left ventricular pseudoaneurysm. J Invasive Cardiol 2012; 24(6): E111-4.

13. Chandrashekar R, Konda MK, Gupta V, Kalavakunta JK. Left Ventricular pseudoaneurysm dissecting into the anterior chest wall: a rare cause of sudden onset excruciating chest pain. Eur J Case Rep Intern Med 2017; 4(1):

14. Afonso Nogueira M, Fiarresga A, de Sousa L, Agapito A, Galrinho A, Cruz Ferreira R. Percutaneous closure of a giant left ventricular wall pseudoaneurysm: Anterograde approach with a double snare technique. Rev Port Cardiol 2016; 35(7-8): 441.e1-4.

15. Agarwal C, Goel S, Jacobi A, Love B, Sanz J. CT imaging of post- myocardial infarction ventricular septal defect with a contained rupture/pseudoaneurysm. Indian Heart J 2015; 67 Suppl 3(Suppl 3): S107-9.

16. Al Saidi K, Malik SA, Albulushi A, Moulton M, Chatzizisis YS. Left ventricular pseudoaneurysm complicated with very late rupture 5 years after myocardial infarction. JACC: Case Reports 2019; 1(4): 569-72.

17. Alexanderson-Rosas E, Mondaca-Garcia O, Zambrano- Guatibonza H, Flores-Garcia A, Carvajal-Juarez I, Espinola- Zavaleta N. Multimodality assessment of ventricular pseudoaneurysm after non-reperfused acute myocardial infarction. J Nucl Cardiol 2019; 26(4): 1368-72.

18. Allende NG, Santos R, Sokn FJ, Merino SA, Accastello GM, Medina JC, et al. Unusual presentations of cardiac rupture during COVID-19 pandemic. Echocardiography 2021; 38(3): 469-72.

19. Al-Mehisen R, Chan KL. Pulsatile chest wall mass complicating myocardial infarction: assessment by two-dimensional, three- dimensional, and contrast echocardiography. Can J Cardiol 2014; 30(6): 697.e3-4.

20. Alshammari BS, Reardon MJ, Nabi F. Late left ventricular pseudoaneurysm after acute myocardial infarction. Methodist Debakey Cardiovasc J 2017; 13(3): 169-71.

21. Alshehri HZ, Momenah TS, AlBaradai A, Sallam A, Alassal MA, Lawand S. Successful percutaneous closure of post myocardial infarction left ventricular ruptured pseudoaneurysm after failed surgical repair. J Cardiol Cases 2014; 9(4): 154-7.

22. Arnáiz-García ME, González-Santos JM, Iscar-Galán A, Fernández García-Hierro JM, Dalmau-Sorlí MJ, López- Rodríguez J. Postoperative recurrence of postinfarction true and false ventricular aneurysms. Rev Port Cardiol 2016; 35(5): 311. e1-3.

23. Ashraf H, Sadatnaseri A, Aminorroaya A, Kuhi Z, Saleh SK. Left ventricular pseudoaneurysm as a complication of myocardial infarction; a case series and review of the literature. Front Emerg Med 2021; 5(3): e30.

24. Aykan AC, Zehir R, Karabay CY, Cakal S, Poci NA, Sönmez

K. Acute anterior myocardial infarction in an 85-year-old male patient, complicated by the deadly duo: ventricular septal rupture and pseudoaneurysm. Cardiovasc J Afr 2012; 23(9): e1-3.

25. Bai W, Tang H. Left ventricular pseudoaneurysm following acute myocardial infarction. Anatol J Cardiol 2018; 20(6): E10-E11.

26. Bansal RC, Khazai B, Bansal N, Dua A. Left ventricular pseudoaneurysm due to embolic myocardial infarction in infective endocarditis: real time three-dimensional transesophageal echocardiographic evaluation. Echocardiography 2011; 28(2): E28-30.

27. Bhardwaj R, Sondhi S, Mehta A. Unruptured giant left ventricular pseudoaneurysm after silent myocardial infarction. BMJ Case Rep 2018 Jul 18; 2018: bcr2018225812.

28. Bhullar AS, Sandhu CS, Bhullar MS, Rathod A. Unusual presentation of left ventricular rupture. BMJ Case Rep 2020; 13(1): e231680.

29. Bisoyi S, Dash AK, Nayak D, Sahoo S, Mohapatra R. Left ventricular pseudoaneurysm versus aneurysm a diagnosis dilemma. Ann Card Anaesth 2016; 19(1): 169-72.

30. Cacciapuoti F, Tirelli P, Cacciapuoti F. Left ventricular postinfarction pseudoaneurysm: diagnostic advantages of three-dimensional echocardiography. J Cardiovasc Echogr 2017; 27(2): 74-6.

31. Carvalho D, Mimoso J, de Jesus I, Fragata J. One aneurysm and two pseudoaneurysms, same patient. BMJ Case Rep 2019; 12(2): e227566.

32. Çelebi AS, Çelebi ÖÖ, Diker E. A huge left ventricular pseudoaneurysm manifesting as acute dyspnea. Int J Cardiovasc Acad 2015; 1(1): 29-30.

33. Chu MWA, Bergin L. Post-myocardial infarction left ventricular rupture. Can J Cardiol 2014;30(8):957.e1-2. doi: 10.1016/j. cjca.2014.03.031.

34. Coelho SG, Jorge CF, Carlos PB, Delgado A, Vicente L. Evolved inferior wall myocardial infarction with left ventricular pseudoaneurysm: a diagnostic dilemma. Arq Bras Cardiol 2020; 114(4): 730-1.

35. Collier P, Phelan D, Soltesz E, Aljaroudi W. Left ventricular pseudoaneurysm: “to-and-fro” flow. J Am Coll Cardiol 2013; 61(8): 896.

36. Cortese F, Costantino MF, Ciccone MM, Calculli G. A perforated cardiac pseudoaneurysm complicating an acute myocardial infarction. J Cardiovasc Med (Hagerstown) 2018; 19(12): 756-7.

37. Della Rocca DG, Forleo GB, Stazi CA, Franco G, Volpe GA, Romeo F. Massive left ventricular pseudoaneurysm 20 years after acute myocardial infarction. J Am Coll Cardiol 2013; 62(23): e523.

38. Derih AY, Yümün G, Erdolu B, Eriş C. Late ruptured giant left ventricular pseudoaneurysm following myocardial infarction: case report. Turkiye Klinikleri J Case Rep 2014; 22(4): 233-5.

39. Díaz-Navarro R, Nihoyannopoulos P. Post-myocardial infarction left ventricular pseudoaneurysm diagnosed incidentally by echocardiography. Echo Res Pract 2017; 4(4): K37-K40.

40. Díez-Villanueva P, Sarraj A, Navarrete G, Salamanca J, Pozo E, Reyes G, et al. Surgical repair of huge left ventricular pseudoaneurysm after suturelessrepair of free wall rupture. Ann Thorac Surg 2017; 103(2): e157-e159.

41. Dimitrovska L, Dolores U, Breskvar Kač, Ambrožič J, Bervar M. Pseudoaneurysm of the left ventricle after myocardial infarction: a case report. Cardiol Croat 2017; 12(4): 122.

42. Driessen R, Sardari Nia P, Roekaerts P, Delnoij T. Cardiac rupture with giant left ventricular pseudoaneurysm following inferior wall myocardial infarction: A rare complication. Acute Card Care 2015; 17(2): 33.

43. Dubey L, Timala R, Adhikari R, Sharma S, Gautam M, Gautam

S. Unruptured left ventricular pseudoaneurysm following inferior wall myocardial infarction. Cardiol J 2012; 19(5): 539-42.

44. Erdim R, Yildirimturk O, Polat B, Aytekin S, Demiroglu C, Aytekin V. Left ventricular pseudoaneurysm complicating inferior myocardialinfarction: a case report. Int J Angiol 2011; 20(2): 107- 10.

45. Falcetta G, Pratali S, De Martino A, Celiento M, Bortolotti U. Repair of a giant left ventricular pseudoaneurysm with rupture of the interventricular septum. Gen Thorac Cardiovasc Surg 2019; 67(9): 800-2.

46. Faustino M, Ranchordás S, Abecasis J, Freitas A, Ferreira M, Gil V, et al. Left ventricular pseudoaneurysm - a challenging diagnosis. Rev Port Cardiol 2016; 35(6): 373.e1-6.

47. Ferati F, Ferati A, Preshova A, Karemani M, Karemani N. Two

different ways of left ventricular pseudoaneurysm formation after


myocardial infarction – case reports. Cardiol Croat 2021; 16(1-2): 50-1.

48. Fernandes RM, Mota T, Azevedo P, Cunha S, Bento D, Marque N, et al. Giant left ventricular (pseudo?) aneurysm complicating anterior myocardial infarction. J Am Coll Cardiol Case Rep 2021; 3(2): 334-8.

49. Fok M, Bashir M, Hammoud I, Harrington D, Kuduvalli M, Field M, et al. An apical left ventricular aneurysm rupture presenting as left breast mass 11 years after surgical repair. Ann R Coll Surg Engl 2014; 96(7): e6-7.

50. Fukunaga N, Rao V. A huge postinfarction left-ventricular pseudoaneurysm: a life-threatening complication of an inferior infarct. CJC Open 2020; 2(6): 748-9.

51. Garg P, Rajashekar P, Airan B. Giant left ventricular pseudoaneurysm following inferior wall myocardial infarction-a case report. Indian J Thorac Cardiovasc Surg 2013; 29(2): 131-3.

52. Ghosh SK, Majumder B, Ghosh S, Chatterjee S, Agarwal M. Symmetrical peripheral gangrene complicating ventricular pseudoaneurysm: a report of an unusual case and a brief review of the literature. An Bras Dermatol 2016; 91(5 suppl 1): 169-71.

53. Grant EN, Huang N, Joshi GP, Aguirre MA. Dual presentation of a giant left ventricular pseudoaneurysm and trueaneurysm. Proc (Bayl Univ Med Cent) 2012; 25(1): 28-30.

54. Guerreiro RA, Congo K, Carvalho J, Pais J, Brás D, Piçarra B, et al. Left ventricular basal inferior pseudoaneurysm and left atrial dissection after myocardial infarction: Case report. Echocardiography 2017; 34(6): 939-41.

55. Güneş T, Alşalaldeh M, Kılıç ID, Emrecan B. Surgical treatment of giant cardiac aneurysm with pseudoaneurysm in a colon carcinoma patient. Kardiochir Torakochirurgia Pol 2015; 12(2): 155-8.

56. Gurzun M-M, Şerban M, Popescu BA, Ginghină C. Ecocardiography: Pseudo-pseudoaneurysm – natural evolution of a rare myocardial infarction mechanical complication. Roman J Cardiol 2013; 23(1): 56-7.

57. Hamamoto M, Morifuji K. Surgery for left ventricular pseudoaneurysm: thoracotomy or sternotomy. Asian Cardiovasc Thorac Ann 2013; 21(5): 602-4.

58. Hinton J, Hunter G, Dissanayake M, Hatrick R. Acute respiratory distress secondary to a huge chronic left ventricular pseudo- aneurysm. Echo Res Pract 2019; 6(4): K19-K22.

59. Hiraoka A, Kuinose M, Chikazawa G, Yoshitaka H. Endoscopic repair for left ventricular pseudoaneurysm with right minithoracotomy. Interact Cardiovasc Thorac Surg 2013; 16(1): 85-7.

60. Ho HH, Sinaga DA, Lee E, Watson TJ, Hon JK. Left ventricular pseudoaneurysm. J Geriatr Cardiol 2017; 14(1): 78-80.

61. Hsieh YK, Lee CH, Chen YS, Wu IH. Pseudoaneurysm after sutureless repair of left ventricular free wall rupture: Sequential magnetic resonance imaging demonstration. Asian J Surg 2015; 38(3): 174-6.

62. Ibrahim M, Gumm DC. Left ventricular pseudoaneurysm following undiagnosed myocardialinfarction: the curious case of the woman with three ventricles. BMJ Case Rep 2015; 2015: bcr2015211597.

63. Imoto K, Kawahito K, Misawa Y. Giant left ventricular pseudoaneurysm following myocardial infarction. Heart 2015; 1(5): 120-3.

64. Inoue T, Hashimoto K, Bando K, Yoshitake M. Left ventricular pseudo-false aneurysm perforating into the right ventricle. Interact Cardiovasc Thorac Surg 2015; 21(1): 137-9.

65. Irazusta FJ, Ramirez U, Caro-Codon J, Refoyo E, Garrido D, Pinilla I, et al. Extensive chest wall destruction secondary to a large ventricle pseudoaneurysm: A surgical challenge. Ann Thorac Surg 2017; 103(3): e227-e229.

66. Jáuregui B, Sobrino JM, Lage E, López-Haldón JE, Martínez A. Giant unruptured left ventricular pseudoaneurysm as a rare cause of heartfailure after an unnoticed coronary ischaemic event. Eur Heart J Cardiovasc Imaging 2013; 14(7): 720.

67. Kadavath S, Ayan M, Al-Hawwas M. Dynamic systolic compression of the left anterior descending coronary artery as the first clue of postinfarction left ventricular pseudoaneurysm. Can J Cardiol 2019; 35(10): 1419.e9-1419.e11.

68. Kansiz E, Hatemi AC, Tongut A, Cohcen S, Yildiz A, Kilickesmez K, et al. Surgical treatment of a giant postero-inferior left ventricular pseudoaneurysm causing severe mitral insufficiency and congestive heart failure. Ann Thorac Cardiovasc Surg 2012; 18(2): 151-5.

69. Kara İ, Ay Y, Anasız H, Yıldırım T, Arsan S. Successful surgical treatment of a chronic pseudoaneurysm of the left ventricle. Kocaeli Med J 2012; 1(2): 39-42.

70. Karaca O, Gunes HM, Cakal B, Turkoglu H. Giant left ventricular pseudoaneurysm concomitant with severe mitral regurgitation: multimodality imaging and successful surgical repair. Eur J Cardiothorac Surg 2015; 47(4): e162-3.

71. Karaji I, Bleie Ø, Skromme K, Davidsen C. Coexisting left ventricular aneurysm and pseudoaneurysm after inferior wall myocardial infarction. Eur Heart J Cardiovasc Imaging 2020; 21(10): 1089.

72. Keskin M, Keskin T, Aybay MN. A giant left ventricular pseudoaneurysm presenting with transient ischemic attack 7 years after acute myocardial infarction: A deep investigation via multiple imaging modalities. Anatol J Cardiol 2016; 16(10): E17-E19.

73. Koklu E, Arslan S, Yuksel IO, Bayar N, Yilmaz GM, Kucukseymen

S. Management of left ventricular free wall rupture associated with acute myocardial infarction. J Acute Med 2017; 7(1): 31-4.

74. Korkmaz K, Lafçi G, Gedik HS, Budak AB, Yener AÜ, Ecevit AN, et al. Surgical treatment of post-infarct left ventricular pseudoaneurysm with on-pump beating heart technique. Cardiovasc J Afr 2014; 25(5): e1-4.

75. Kumar S, Moorthy N, Kapoor A, Sinha N. Post myocardial infarction left ventricular giant pseudoaneurysm. Heart Views 2011; 12(3): 118-9.

76. Kusadokoro S, Hori D, Fujii K, Yamaguchi A. Left thoracotomy approach for left ventricular pseudoaneurysm due to myocardial infarction after mitral valve replacement for papillary muscle rupture. J Card Surg 2020; 35(8): 2103-5.

77. Landi A, Andres AL, Napodano M. Late recurrence of a giant left ventricular pseudoaneurysm: the importance of multimodality imaging approach. Monaldi Arch Chest Dis 2020; 90(1).

78. Lanzellotti D, Marzot F, Guglielmi C, Panfili M. Impending myocardial rupture: is an early surgical treatment enough? BMJ Case Rep 2011; 2011: bcr0720114498.

79. Lee CH, Lee DK, Lim SH, Kim H. Anesthetic management during surgery for left ventricular aneurysm and false aneurysm occurring in stage: a case report. Korean J Anesthesiol 2016; 69(5): 518-22.

80. Letonja M, Letonja MS. With computed tomography confirmed anterolateral left ventricularpseudoaneurysm in patient with dilatative alcoholic cardiomyopathy. Radiol Oncol 2011; 45(3): 180-3.

81. Li X, Wang Y, Wang D, Lai C, Wang C. The evolution of left ventricular pseudoaneurysm from the rupture of leftventricular free wall following acute myocardial infarction: a case report. BMC Cardiovasc Disord 2020; 20(1): 5.

82. Lopez-Mattei JC, Nabi Fl, Little SH, Shah D. Museum of TMH Multimodality Imaging Center. Left ventricular pseudoaneurysm. Methodist Debakey Cardiovasc J 2013; 9(2): 114.

83. Ludmir J, Kapoor K, George P, Khural J, Barr B. Left ventricular pseudoaneurysm following inferior myocardial infarction: a case for conservative management. Cardiol Res 2016; 7(1): 32-5.


84. Madan T, Juneja M, Raval A, Thakkar B. Transcatheter device closure of pseudoaneurysms of the left ventricular wall: an emerging therapeutic option. Rev Port Cardiol 2016; 35(2): 115. e1-5.

85. Maeba H, Miyasaka Y, Kotaka A, Tsujimoto S, Yuasa F, Iwasaka T. Pseudoaneurysm with left-to-right shunt in a patient with myocardialinfarction: evaluation by three-dimensional echocardiography. J Med Ultrason 2012; 39(3): 169-72.

86. Mahesh B, Ong P, Kutty R, Abu-Omar Y. Tamponade by an expanding left ventricular pseudoaneurysm: A unique presentation. Asian Cardiovasc Thorac Ann 2015; 23(8): 976-8.

87. Mathur M, Gupta S. Cardiac pseudoaneurysm - a death defying entity. J Clin Diagn Res 2016; 10(6): TD06-TD07.

88. Melman YF, Levy MS, Laham RJ. Intracardiac echocardiography and fluoroscopy guided percutaneous left ventricular pseudoaneurysm closure. Catheter Cardiovasc Interv 2013; 82(7): E915-8.

89. Meng X, Yang YK, Yang KQ, Zhang Y, Lu PP, Fan P, et al. Clinical characteristics and outcomes of left ventricular pseudoaneurysm: a retrospective study in a single-center of China. Medicine (Baltimore) 2017; 96(18): e6793.

90. Meor A, Ajani AE. Late post-infarction left ventricular pseudoaneurysm: a case report. Cardiovasc Revasc Med 2020; 21(1): 145-6.

91. Miyagawa A, Okamura H, Kitada Y, Arakawa M, Adachi

H. Double-patch and glue repair of a postinfarction left ventricularpseudoaneurysm. Asian Cardiovasc Thorac Ann 2021; 29(2): 116-8.

92. Miyoshi F, Seino Y, Nomura M, Ozaki M. Intraoperative real- time three-dimensional transesophageal echocardiography as a precise navigator for a successful complicated postoperative left ventricularpseudoaneurysm repair: a case report. JA Clin Rep 2019; 5(1): 41.

93. Mohamed E, Telila T, Osaki S, Jacobson K. Percutaneous closure of left ventricle pseudoaneurysm using 3D printedheart model for procedure planning: a novel approach. Catheter Cardiovasc Interv 2019; 94(6): 874-7.

94. Monopoli DE, Cimato P, Rossi R. Huge postmyocardial infarction left ventricular pseudoaneurysm in a patient with previous self- inflicted thoracic stab wounds. J Cardiovasc Surg (Torino) 2014; 55(2): 302-5.

95. Mujanovic E, Bergsland J, Avdic S, Stanimirovic-Mujanovic S, Kovacevic-Preradovic T, Kabil E. Surgical treatment of left ventricular pseudoaneurysm. Med Arh 2014; 68(3): 215-7.

96. Nakashima R, Yamaguchi K, Yoshitomi H, Okada T, Endo A, Tanabe K. A case of myocardial infarction and left ventricular pseudo-false aneurysm perforating the right ventricle. J Echocardiogr 2017; 15(2): 91-2.

97. Naseerullah FS, Baig M, Wool KJ, Murthy A. Left ventricle pseudoaneurysm: diagnosis by a new murmur. J Cardiol Cases 2018; 18(1): 20-4.

98. Niemann M, Hermann M, Jacobs S, Gotschy A, Gordic S, Tanner FC, et al. The third ventricle--a case of a giant post infarct pseudoaneurysm. Int J Cardiol 2014; 177(3): e93-6.

99. Niimura H, Mito T, Matsunaga A, Koga S, Akasu K, Morishige N, et al. Left ventricular pseudoaneurysm following acute myocardial infarction. Intern Med 2006; 45(21): 1221-3.

100. Okada M, Watanuki H, Sugiyama K, Futamura Y, Matsuyama

K. Unusual rupture of left ventricular pseudo-false aneurysm secondary to subacute anterolateral myocardial infarction: a case report. J Cardiothorac Surg 2019; 14(1): 93.

101. Orsborne C, Schmitt M. Left ventricular pseudoaneurysm after myocardial infarction detected by cardiac MRI. BMJ Case Rep 2014; 2014: bcr2014207277.

102. O’Sullivan CJ, Groza D, Eberli FR. Left ventricular pseudoaneurysm formation in a patient presenting with a subacute myocardial infarction. BMJ Case Rep 2017; 2017: bcr2017222481.



103. Ousaka D, Obara N, Fujiwara M, Nakagawa K, Teraoka A, Kasahara S, et al. A case of conservative management for left ventricular giant pseudoaneurysmwithout ST segment changes. J Cardiol Cases 2018; 17(5): 167-70.

104. Parikh RV, Ahmadi-Kashani M, Fleischmann D, Woo YJ, McConnell MV. A crack in the wall: evolution of a left ventricular apical pseudoaneurysm. Can J Cardiol 2016; 32(6): 830.e7-8.

105. Park WK, Kim DH, Cho SH. Large chronic pseudoaneurysm of left ventricle complicating anterior myocardial infarction. Korean Circ J 2018; 48(8): 760-2.

106. Patel P, Siegenthaler M, Bandettini WP, Arai AE, Fujikura K. Left ventricular pseudoaneurysm in a patient with an apical aneurysm. JACC Case Reports 2020; 3(1): 91-3.

107. Petrou E, Vartela V, Kostopoulou A, Georgiadou P, Mastorakou I, Kogerakis N, et al. Left ventricular pseudoaneurysm formation: two cases and review of the literature. World J Clin Cases 2014; 2(10): 581-6.

108. Pineda-De Paz DO, Hernández-Del Rio JE, González-Padilla C, Esturau-Santaló RM, Romero-Palafox J, Grover-Paez F, et al. Left ventricular free-wall rupture, a potentially lethal mechanicalcomplication of acute myocardial infarction: an unusual and illustrative case report. BMC Cardiovasc Disord 2019; 19(1): 80.

109. Prifti E, Bonacchi M, Baboci A, Giunti G, Veshti A, Demiraj A, et al. Surgical treatment of post-infarction left ventricular pseudoaneurysm: case series highlighting various surgical strategies. Ann Med Surg (Lond) 2017; 16: 44-51.

110. Radhakrishnan BK, Kumar CJ, Philipose S, Karunakaran J. A large left ventricular pseudoaneurysm. Eur J Cardiothorac Surg 2016; 49(4): 1291-2.

111. Reyaldeen R, Jeffries C, Hardman D, Challa P, Dahiya A. Multimodality imaging in a case of chronic massive left ventricular pseudoaneurysm. CASE (Phila). 2018; 2(3): 95-8.

112. Roa-Castro VH, Molina-Bello E, Valenzuela-Suárez H, Rotberg- Jagode T, Espinola-Zavaleta N. Survival after left ventricular free wall rupture in an elderly woman with acute myocardial infarction treated only medically. Case Rep Vasc Med 2012; 2012: 728602.

113. Ropers D, Achenbach S, Pfeiffer S. Left ventricular pseudoaneurysm following myocardial infarction. Heart 2004; 90(5): 555.

114. Sadeghpour A, Pourafkari L, Khesali H, Nader ND. Chronic large pseudoaneurysm of the left ventricle. Intern Emerg Med 2020; 15(1): 145-6.

115. Sakakibara K, Matsumoto M, Kaga S, Suzuki S. Giant left ventricular pseudoaneurysm after myocardial infarction. Intern Med 2012; 51(4): 445-6.

116. San Antonio R, Caldentey G, Flores E, Martínez M. Heart failure after acute myocardial infarction: giant pseudoaneurysm that was difficult to diagnose because of imaging techniques. Intensive Care Med 2016; 42(7): 1174-5.

117. Saran M, Pradhan A, Sethi R, Narain VS. Giant posterobasal pseudoaneurysm: An unusual presentation of inferior wall myocardial infarction. IHJ Cardiovascular Case Reports (CVCR) 2018; 2(2): 99-101.

118. Sasaki K, Fukui T, Tabata M, Takanashi S. Early pseudoaneurysm formation after the sutureless technique for left ventricular rupture due to acute myocardial infarction. Gen Thorac Cardiovasc Surg 2014; 62(3): 171-4.

119. Shimono H, Kajiya T, Atsuchi Y, Atsuchi N, Ohishi M. Giant left ventricular pseudo-aneurysm after posterior myocardial infarction. Eur Heart J 2018; 39(37): 3479.

120. Shimono H, Kajiya T, Inoue H, Ueno M, Takaoka J, Atsuchi Y, et al. Left ventricular pseudo-aneurysm with ventricular septal rupture due to anterior ST-segment elevation myocardial infarction. Intern Med 2019; 58(13): 1901-5.

121. Shreetal RN, Sajeer K, Sandeep R, Rajesh GN, Haridasan V, Sadanadan R, et al. Double ventricular rupture after acute myocardial infarction: a rare case report. Indian Heart J 2015; 67 Suppl 3(Suppl 3): S21-3.


122. Si D, Shi K, Gao D, Yang P. Ruptured left ventricular pseudoaneurysm in the mediastinum followingacute myocardial infarction: a case report. Eur J Med Res 2013; 18(1): 2.

123. Silveira I, Rodrigues P, Gomes C, Torres S. Giant left ventricular pseudoaneurysm as a late complication of myocardial infarction. J Cardiovasc Echogr 2018; 28(1): 67-8.

124. Singh A, Kliger C, Ruiz CE. Novel approach for the percutaneous treatment of left ventricularpseudoaneurysms. Catheter Cardiovasc Interv 2015; 85(6): 1092-6.

125. Smolka G, Peszek-Przybyla E, Sosnowski M, Ochala A. Complete percutaneous obliteration of a post-infarction left ventricular inferior wall pseudoaneurysm. JACC Cardiovasc Interv 2012

;5(8): 886-7.

126. Sokolskaya N, Kopylova N, Slivneva I, Kolesnikov Y, Alshibaya M, Zakharkina M. Echocardiographic diagnosis of a massive left ventricular pseudoaneurysm: a case report. Kardiochir Torakochirurgia Pol 2015; 12(2): 181-3.

127. Song YS, Seol SH, Kim SH, Kim DK, Kim KH, Kim DI, et al. Delayed left ventricular pseudo-aneurysm after postinfarction repair of ventricular septal defect. Cardiovasc J Afr 2019; 30(1): e1-e3.

128. Soud M, Moussa Pacha H, Hritani R, Alraies MC. Post myocardial infarction left ventricular pseudoaneurysm. Cardiovasc Revasc Med 2018; 19(2): 199-200.

129. Sousa P, Santos W, Cordeiro P, Pereira S, Ferrinha R, Brandão V, et al. Pseudoaneurysm inside of a true aneurysm. J Cardiothorac Surg 2013; 8: 97.

130. Subban V, Kurian VM, Ajit MS, Kumar RS. Hybrid trans-apical device closure of left ventricular pseudoaneurysm under trans- oesophageal echocardiographic guidance. Heart Lung Circ 2012; 21(11): 734-6.

131. Tang L, Tang JJ, Hu XQ, Fang ZF, Zhu ZW, Chen YQ, et al. Transcatheter closure of complex post-myocardial infarction left ventricular pseudoaneurysm and unique post-traumatic right ventricular pseudoaneurysm. Int Heart J 2019; 60(4): 998-1002.

132. Tsai IC, Lin MC, Jan SL, Fu YC. Multidetector row computed tomography for percutaneous closure of a left ventricular free wall rupture after myocardial infarction. JACC Cardiovasc Interv 2015; 8(11): e175-e176.

133. Unai S, Ohno T, Miyairi T. Left ventricular pseudoaneurysm following myocardial infarction. J Card Surg 2013; 28(1): 47.

134. Valério RS, Oshiro FS, Rodrigues AA, Siqueira ME, Uellendahl

M. Left ventricular free-wall rupture (pseudoaneurysm) after acute myocardial infarction in an asymptomatic patient. Arq Bras Cardiol Imagem Cardiovasc 2021; 34(1): eabc134.

135. Vijayvergiya R, Kumar A, Rana SS, Singh H, Puri GD, Singhal M. Post-myocardial infarction giant left ventricular pseudoaneurysmpresenting with severe heart failure. World J Cardiol 2012; 4(11): 309-11.

136. Villanueva C, Milder D, Manganas C. Ruptured left ventricular false aneurysm following acute myocardialinfarction: case report and review of the literature. Heart Lung Circ 2014; 23(12): e261- 3.

137. Vo AT, Nguyen TT, Tran TT, Nguyen DH. Conservative treatment of postinfarction left ventricular free wall rupture. Case Rep Cardiol 2020; 2020: 8832578.

138. Wdowiak-Okrojek K, Lipiec P, Szewczyk M, Lubiński A, Kasprzak JD. Successful surgical repair of a chronic left ventricular pseudoaneurysm. Kardiochir Torakochirurgia Pol 2013; 10(3): 279-82.

139. Webb J, Gemmell RM, Al-Fakih K, Chiribiri A. Medical treatment of left ventricular pseudoaneurysms. QJM 2016; 109(3): 213-4.

140. White JM, Lowe BS, Ruygrok PN. A man with 3 lives: long- term follow-up following percutaneous closure of leftventricular pseudoaneurysm neck. JACC Cardiovasc Interv 2015; 8(5): e77-9.

141. Wieczorek J, Mizia-Stec K, Rybicka-Musialik A, Janusiewicz P, Malinowski M, Deja MA. A large pseudoaneurysm of the left cardiac ventricle in a 57-year-old patient after urgent coronary artery bypass grafting and surgical mitral valve replacement due to acute myocardial infarction. Kardiochir Torakochirurgia Pol 2014; 11(4): 432-6.

142. Witalka T, Smith M, Lee S. Anterior wall ventricular pseudoaneurysm presenting as dizziness and syncope. Am J Emerg Med 2019; 37(1): 175.e3-175.e5.

143. Wolf M, Vermeersch P, Van Reet B, Van den Branden FL. Early surgical repair of an acute post-infarction left ventricularpseudoaneurysm complicated by second pseudoaneurysm formation. Acta Cardiol 2012; 67(6): 723-6.

144. Yıldız İ, Özmen Yıldız P, Gürbak İ, Kaya B. Case image: left ventricular pseudoaneurysm as a silent complication of non-ST segment elevation myocardial infarction. Turk Kardiyol Dern Ars 2018; 46(2): 164.

145. Yılmaztepe M, Öztürk C, Uçar FM, Kaya Ç, Gürdoğan M. Left ventricle pseudoaneurysm detected eight months after myocardialinfarction. Turk Kardiyol Dern Ars 2019; 47(3): 246.

146. Yoshida R, Takagi K, Morita Y, Morishima I. Incidentally discovered left ventricular pseudoaneurysm after silentmyocardial infarction occurred in a young woman with peritoneal dialysis. Eur Heart J 2019; 40(18): 1474.

147. Bildirici U, Agacdiken A, Ural E, Kahraman G, Komsuoglu B. Two cases with similar pseudoaneurysms but different outcomes. Clin Cardiol 2009; 32(6): E60-2.

148. 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 Cardiol 2010; 139(2): 199-201.

149. Andrade LC, Donato P, Ferreira MJ, Alves FC. Left ventricular false aneurysm characterized by cardiovascular magnetic resonance and late enhancement technique. Acta Radiol Port 2014; 26(101): 35-8.

150. Paul M, Schäfers M, Grude M, Reinke F, Juergens KU, Fischbach R, et al. Idiopathic left ventricular aneurysm and sudden cardiac death in young adults. Europace 2006; 8(8): 607-12.

151. Jha AK, Pandey R, Gharde P, Devagourou V, Kiran U. Idiopathic left ventricular outflow tract pseudoaneurysm. Ann Card Anaesth 2013; 16(3): 209-11.

152. Atik FA, Navia JL, Vega PR, Gonzalez-Stawinski GV, Alster JM, Gillinov AM, et al. Surgical treatment of postinfarction left ventricular pseudoaneurysm. Ann Thorac Surg 2007; 83(2): 526-31.


153. Konarik M, Pokorny M, Pirk J, Netuka I, Szarszoi O, Maly J. New modalities of surgical treatment for postinfarction left ventricular free wall rupture: a case report and literature review. Cor Vasa 2015; 57(5): e359-e361.

154. Patted SV, Halkati PC, Modi R. LV pseudoaneurysm - An unprecedented condition. IOSR J Dental Med Sci (IOSR-JDMS) 2015; 14(19): 69-72.

155. Salaun E, Aldebert P, Jaussaud N, Spychaj JC, Maysou LA, Collart F, et al. Early endocarditis and delayed left ventricular pseudoaneurysm complicating a transapical transcatheter mitral valve-in-valve implantation: percutaneous closure under Local Anesthesia and Echocardiographic Guidance. Circ Cardiovasc Interv 2016; 9(10): e003886.

156. Onik G, Recht L, Edwards JE, Sarosi GA, Bianco JA, Shafter RB. False left-ventricular aneurysm: diagnosis by noninvasive means. J Nucl Med 1980; 21(2): 177-82.

157. Chen JS, Huang JH, Chu SH, Chiu KM. Left ventricular pseudoaneurysm after apicoaortic bypass. Eur J Cardiothorac Surg 2011; 40(3): e132.

158. Garrido JM, Ferreiro A, Rodríguez-Vázquez JF, Prada P, Verdugo S, Silva J, et al. Left ventricle postinfarction pseudoaneurysm: anatomical forms and surgical management. Surg Sci 2014; 5(4): 138-45.

159. Rogers JH, De Oliveira NC, Damiano RJ Jr, Rogers JG. Images in cardiovascular medicine. Left ventricular apical pseudoaneurysm: echocardiographic and intraoperative findings. Circulation 2002; 105(8): e51-2.

160. Natarajan MK, Salerno TA, Burke B, Chiu B, Armstrong PW. Chronic false aneurysms of the left ventricle: management revisited. Can J Cardiol 1994; 10(9): 927-31.

161. Yavuz S. eComment. Ventricular pseudoaneurysms in postsurgical cardiac patients. Interact Cardiovasc Thorac Surg 2014; 19(1): 161-2.

162. Davidson KH, Parisi AF, Harrington JJ, Barsamian EM, Fishbein MC. Pseudoaneurysm of the left ventricle: an unusual echocardiographic presentation. Review of the literature. Ann Intern Med 1977; 86(4): 430-3.

163. Lopes R, Almeida J, Silva JC, Almeida PB, Madureira AJ, Ramos I, et al. Spontaneous closure of a left ventricle pseudoaneurysm following apical venting. Eur J Echocardiogr 2011; 12(2): E6.

164. Lafci B, Ozsöyler I, Emrecan B, Göktogan T, Bozok S, Yasa H, et al. Surgical treatment of postinfarction left ventricular pseudoaneurysms. Heart Surg Forum 2006; 9(6): E876-9.

165. Narayan RL, Vaishnava P, Goldman ME, Stelzer P, Clark L, Kini AS, et al. Percutaneous closure of left ventricular pseudoaneurysm. Ann Thorac Surg 2012; 94(5): e123-5.