jagdish mohan-lv aneurysm

8/8/2019 Jagdish Mohan-LV Aneurysm

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Echo Singapore 2009

LV

AneurysmsHow to image?

What numbers matter ?Does Remodelling Surgery

Help ?

J.C. MohanNew Delhi

India

LV aneurysm is

defined as a discretethin-walled dyskineticor akinetic segment of

the chamber with avariable sizedcommunication to the

LV cavity

McMahon CJ, Moniotte S, Powell AJ, del Nido PJ, Geva T. Usefulness of magneticresonance imaging evaluation of congenital left ventricular aneurysms. Am JCardiol. 2007;100: 310315


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Case #1: 45M symptomatic (HF)chest pain occurred 2 months back following stress

LV

RV

LA

PE

Sharp Discontinuity


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Pseudo-aneurysm with chronic CardiacRupture

PE

Pleural Effusion

LV

Aneurysm

Dors Procedure

26/3/200825/5/2009

Operated in April 2008


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Case #2:40-yr male. AMI on Dec 10 , 2009

January 14 , 2009June 2, 2009

W

6month Follow-up on Ace-I/BB/Eplerinone

Wide-necked Pseudoaneurysm


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Case#3: 64-yr male with old inferiorMI and class II Dyspnoea

Pre-op

April 28,2 005

Post-op

Sept 12, 2009

True aneurysm

LocalisedOutpouched anddyskineticthinned out

myocardiumhaving all the 3layers

Pseudoaneurysm

Cardiacrupture

containedby adherent

pericardiumor scartissue

True LV Aneurysm

Injured or infarcted myocardium displays greaterplasticityor creep, defined as deformation or stretch overtime under a constant load


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Pseudo-aneurysm: Followinginferoposterior MI

True or False

True aneurysm, which occurs in 5%10%of patients with AMI , does not tend torupture at the chronic stage and therefore,in the absence of other indications forsurgery (eg, refractory angina pectoris,congestive heart failure, systemic

embolization, or refractory arrhythmia) istreated medically

False aneurysm usually is treatedsurgically Pseudoaneurysm is more

frequent than recognised

True Left ventricular aneurysms occur

with the long-term form of infarctexpansion

cardiac rupture is an extreme form of

acute infarct expansion which may resultin pseudoaneurysm subsequently


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Pseudo-pseudoaneurysm

Cardiac rupturecontained by

outer or

subepicardial

muscular layer

No visible Communication with LV Cavity

Subepicardial Aneurysm:Visiblecommunication of ruptured tract

Post-MI Pseudo-pseudo

Aneurysm


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Imaging Modalities

Echo MRI

Cath Angio

CT Angio

Radionuclide studies

positron-emission tomography (PET) can behelpful early after infarction to differentiate trueaneurysm from hibernating myocardium withreversible dysfunction

True Aneurysm

Ischemic

Congenital

HCM

Infective ( Chagas Disease)

Sarcoidosis

Trauma

Flow Jet Lesions

After Apical Venting or CMV

Of 1299 HCM

patients, 28 (2%)were identified withleft ventricular apical

aneurysms, includinga pair of identicaltwins

Maron et alSept 22,2008Circulation

Prognostically significant


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True Apical Aneurysm in HCM

left ventricular apexhas to be considereda locus minorisresistentiaedue to the

thinner helicalarchitecture ofmyocardium in theapical loop

Post-infarct vs HCM

Cardiac MRI : apical LV aneurysm is

associated with myocardialhyperenhancement a nd a lower e jection

fraction and that apical LV thinning is acommon finding in HCM with asymmetrical

septal hypertrophy and it does not showdelayed enhancement

65-yr female with normal CAG

Congenital True Aneurysm

LV


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5-year post-MVR33-yr male

Pseudoaneurysm: Etiology

IHD(MI) 55%

Post-surgery 33%

Trauma 7%

Infections 5%

Congenital ( inter-annular

discontinuity )JACC 1998

Frances C et alTrue natural historyrem ains ill-

defined with 30-45% rupture rates

Pseudoaneurysms More often inferoposterior/lateral

Narrow Neck ( orificediameter/internal diameter ofaneurysm 0.25-0.5 vs 0.9-1.0)

Turbulent to-and-fro flow

Stagnation/SEC/thrombi

Sudden loss of myocardial integrity

Sharp discontinuity of endocardium

Pseudoaneurysm expands in

Systole

Pericardial hyperenhancement


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TB Pseudo-aneurysmPresenting as HF

Wide-necked Pseudo-aneurysm

LV

LA


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Wide-necked False Aneurysms

Only 4% ondiaphragmatic/posterior region are true

Wide Neck is possible

Endocardium/myocardial cells present inwall in true aneurysm

Post-MVR: SubmitralPseudoaneurysm

Bantus Aneurysm or Congenital

Subannular aneurysm


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25-yr male with HF: PAN

Bantus Submitral Aneurysm

Pseudoaneurysms 75% have non-specific ST-T changes on

ECG

Symptomatic 88%HF

Chest painDyspnoea

SCD

Asymptomatic

12%

Frances C et al: JACC 1998;32:557

N=290 ( literature review)


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Differential Diagnosis

Diverticulum True LV aneurysm

1. Contractile outpouching

2. Narrow neck

3. Full thickness healthy

muscular wall

4 No alteration in rest

of LV ge ometry

5. Associations

1. Non-contractile

2. Broad-neck

3. Scar a nd Q wave on ECGs

4. Altered LV geometry

5. Coronary involvement

6. Usually with MR

Echo and CE-MRI are the bestimaging modalities

Contrast ventriculography was diagnostic

in 54% of patients in whom it wasperformed, as opposed to 97% for two-

dimensional echocardiography (p = 0.2).

Fernando A ,Surgical Tt of LV Pseudo-aneurysmsATS , Feb 2007N=30

Konen E, Merchant N,G utierrez C, etal: True versus false left ventricular aneurysm:Differentiation with MR i magingInitial experience. Radiology 2005; 236:65

Pericardial enhancement is invariable in false aneurysm but is also

present in 15% of true aneurysms

LAO View:

Contrast Cath-based Angiography tends to miss basalpseudo-aneurysms a nd submitral aneurysms and maydislodge thrombi


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Intense delayedenhancement of thepericardium is notedin all cases of false

aneurysm

Sensitivity 100%Specificity 84%

Contrast-enhanced MRI forThrombi and True vs False

Aneurysm

Mollet et al ( Circ 2002):

TTE 9% vs MRI 21%

German study : TTE

14% vs 41% ( ROFO2005)

Ventricular Reconstructive Surgery

vs Prognosis

Attractive Hypothesis

with limited data


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Grondin et al, Circ 2005

AsymptomaticSymptomatic

Surgical Ventricular Reconstruction

-20%

-18%

-16%-14%

-12%

-10%

-8%

-6%

-4%

-2%

0%

LVESV

CABG CABG+SVR

STICH:Jones RH et al: ACC 2009

SimilarNYHA class

MortalityHospitalisation

P


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Summary ( ctd)

the risk of thromboembolism is low for patientswith aneurysms (0.35% per patient-year), andlong-term anticoagulation is not usuallyrecommended

However, in the 50% of patients with muralthrombus visible by echocardiography after MI,19% develop thromboembolism over a meanfollow-up of 24 months

Reconstructive surgery reduces volumes butdoes not improve prognosis

jagdish mohan-lv aneurysm

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