Large infero-basal left ventricular aneurysm with organized thrombus
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CASE IMAGE IN CARDIOVASCULAR ULTRASOUND
Large infero‑basal left ventricular aneurysm with organized thrombus Kewal Kanabar1 · Krishna Prasad1 · Prithvi Rani2 · Navjyot Kaur1 · Krishna Santosh1 · Saurabh Mehrotra1 Received: 17 May 2019 / Revised: 18 July 2019 / Accepted: 20 July 2019 © Japanese Society of Echocardiography 2019
Case description A 70-year-old asymptomatic hypertensive male was referred when a screening evaluation showed pathological Q waves in the inferior limb leads. He did not have a history of prior myocardial infarction or angina. A transthoracic echocardiogram showed a large posterior left ventricular (LV) submitral aneurysm (67 × 65 mm) with a wide neck (40 mm) along with a layered thrombus within (Fig. 1a and Supplementary Material Video 1). Cardiac magnetic resonance (CMR) imaging confirmed the presence of a large, partially thrombosed infero-basal submitral aneurysm (Fig. 1c, d). An invasive coronary angiogram showed near-total occlusion of the right coronary artery with TIMI 1 flow and chronic total occlusion of the left circumflex artery with retrograde filling. Myocardial perfusion imaging with 99mTc-Sestamibi was suggestive of non-viable basal and mid-inferior and inferolateral segments. The patient was advised to continue guideline-directed medical treatment with aspirin, statin, oral anticoagulation (warfarin) and angiotensin-converting enzyme (ACE) inhibitor. An echocardiogram at 3-month follow-up showed similar findings with significant resolution
of the thrombus (Fig. 1b). The patient has completed 1 year of follow-up and is currently asymptomatic. Left ventricular aneurysms commonly occur after STelevation myocardial infarction due to transmural necrosis. Although these aneurysms are commonly seen in the anterior wall or at the apex in a patient with myocardial infarction due to left anterior descending artery occlusion, large infero-basal aneurysms secondary to right coronary artery or left circumflex artery disease in an asymptomatic patient without a prior history of myocardial infarction are distinctly uncommon. Although anterior aneurysms are commonly filled with organized clots, the occurrence of thrombus in inferior aneurysms is relatively uncommon [1]. The other causes of LV aneurysms include trauma, hypertrophic cardiomyopathy, myocarditis, sarcoidosis, arrhythmogenic right ventricular cardiomyopathy, HIV, and Chagas disease. Patients with LV aneurysms may present with refractory angina, heart failure, malignant ventricular arrhythmias, or systemic embolization, which may warrant surgical intervention [1–3].
Electronic supplementary material The online version of this article (https://doi.org/10.1007/s12574-019-00437-w) contains supplementary material, which is available to authorized users. * Saurabh Mehrotra [email protected] 1
Department of Cardiology, Postgraduate Institute of Medical Education and Research (PGIMER), 3rd Floor, C Block, Faculty Room, ACC, Sector 12, Chandigarh 160012, India
Department of Radiodiagnosis, Postgraduate Institute of
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