jagdish mohan-lv aneurysm
TRANSCRIPT
-
8/8/2019 Jagdish Mohan-LV Aneurysm
1/17
1
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
-
8/8/2019 Jagdish Mohan-LV Aneurysm
2/17
2
Case #1: 45M symptomatic (HF)chest pain occurred 2 months back following stress
LV
RV
LA
PE
Sharp Discontinuity
-
8/8/2019 Jagdish Mohan-LV Aneurysm
3/17
3
Pseudo-aneurysm with chronic CardiacRupture
PE
Pleural Effusion
LV
Aneurysm
Dors Procedure
26/3/200825/5/2009
Operated in April 2008
-
8/8/2019 Jagdish Mohan-LV Aneurysm
4/17
4
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
-
8/8/2019 Jagdish Mohan-LV Aneurysm
5/17
5
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
-
8/8/2019 Jagdish Mohan-LV Aneurysm
6/17
6
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
-
8/8/2019 Jagdish Mohan-LV Aneurysm
7/17
7
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
-
8/8/2019 Jagdish Mohan-LV Aneurysm
8/17
8
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
-
8/8/2019 Jagdish Mohan-LV Aneurysm
9/17
9
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
-
8/8/2019 Jagdish Mohan-LV Aneurysm
10/17
10
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
-
8/8/2019 Jagdish Mohan-LV Aneurysm
11/17
11
TB Pseudo-aneurysmPresenting as HF
Wide-necked Pseudo-aneurysm
LV
LA
-
8/8/2019 Jagdish Mohan-LV Aneurysm
12/17
12
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
-
8/8/2019 Jagdish Mohan-LV Aneurysm
13/17
13
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)
-
8/8/2019 Jagdish Mohan-LV Aneurysm
14/17
14
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
-
8/8/2019 Jagdish Mohan-LV Aneurysm
15/17
15
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
-
8/8/2019 Jagdish Mohan-LV Aneurysm
16/17
16
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
-
8/8/2019 Jagdish Mohan-LV Aneurysm
17/17
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