Guest Editorial
 

Inverted Bulb
A Rare Complication Of Myocardial Infarction- A New Sign!
Jayakeerthi Y, Lokesh, Ravindranath K S Manjunath C N
Sri Jayadeva Institute of Cardiovascular Sciences and Research, Bangalore,

History:
A 45 year old male, a chronic smoker, from a poor socioeconomic background, with no prior cardiac history, presented to us with severe chest pain and back pain, and dyspnea of 15 hours duration. Examination revealed signs of left heart failure. ECG showed ST depression (upto 5mm) in the anterior leads, with Q waves and inverted T waves in inferior leads. Echocardiogram revealed akinesia of the inferior and posterior walls, with an aneurysm of the postero-lateral wall measuring 9 cm*5 cm (larger than the LV) with thrombus (Figs: 1,2,3). The end systolic orifice diameter was 2.5 cm. Posterior mitral leaflet was tethered leading to non-coaptation of mitral leaflets and severe regurgitation. LV ejection fraction was 45%. He had class III dyspnea despite maximal medications. He was advised coronary angiography and early surgery for which he was not willing and died shortly after discharge.
Discussion:

LV aneurysms could be true or false (pseudo). In the setting of a myocardial infarction (MI), a true aneurysm is formed by infarct expansion, while pseudoaneurysm is formed by myocardial rupture contained by the pericardium. Free wall rupture complicating MI, is seen in ~4% of patients and accounts for upto 20% of those suffering fatal infarcts[1,2]. The largest consecutive angiographic data shows the pseudoaneurysm incidence of 0.23%[3].  Cardiac rupture most commonly occurs between 3-6 days after MI[4]. The average duration between the index MI and detection of pseudoaneurysm is 1 month. The most common cause of a pseudoaneurysm is MI, followed by surgery, trauma and infections[5]. The commonest location following MI is the postero-lateral wall followed by apical and inferior walls. In a large series, one third presented with congestive heart failure and chest pain, while 25% presented with dyspnea[5], as did our patient. Whereas patients with true aneurysm have a 70% 3 year survival[6], those with pseudoaneurysm are not thought to be that lucky. Hence, the importance of diagnosing pseudoaneurysms and differentiating them form the true aneurysms. Echocardiographically, lack of myocardium in the aneurysm wall, discontinuity in the myocardium of the ventricle, end-systolic orifice diameter to maximum diameter ratio of the aneurysmal cavity of <0.5 and presence of thrombus differentiate a pseudoaneurysm from a true aneurysm[7].  It is important to study the aneurysm in various planes even if it means using unconventional views. In


the subcostal short axis view, it can be mistaken for a true aneurysm. It is important to locate the orifice to avoid misdiagnosis. Of interest, can we call it the “inverted bulb” sign in subcostal short axis view at the mitral valve plane? (Fig: 3). The LV likened to the globe, the aneurysm to the screw cap and the mitral valve to the filament!! Almost 70% of the post MI pseudoaneurysms are in the posterolateral location, as in this case. The proposed sign should by logic, apply to both true and false aneurysms in this location. Some studies have not shown increased incidence of fatal cardiac rupture with conservative management, with a mean survival rate of ~80% and 70% at 1 and 4 years[8,9]. Stroke rates in these patients were 10% and 30% at 1 and 4 years respectively, providing a case for anticoagulation. However, large pooled data showed worse results with conservative management, and almost half were dead by 1 week[5], while the 2-year mortality was 50% in another study[3]. Surgical mortality has ranged from 7 to29%[5,7,10], being lower in more recent reports.

Figure 1: 9*5cm pseudoaneyrusm seen in apical 4 chamber view

 

 

Correspondence:.Dr Jayakeerthi Y*Assistant Professor,{SJICSAR}1425, South End ‘A’ Cross,26th Main, 9th Block Jayanagar, Bangalore Karnataka,- 560069 India
Email: jayakeerthiy@in.com; victorfame@gmail.com
Indian Heart J. 2010; 62:357-358
 
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Figure 3: Subcostal short axis view showing the large aneurysm involving the posterolateral wall with thrombus, in diastole and systole. The light bulb for comparison to the diastolic frame (see text)

 
References:
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6.Faxon DP, Ryan TJ, Davis KB, et al. Prognostic significance of angiographically documented left ventricular aneurysm from the Coronary Artery Surgery Study (CASS). Am J Cardiol. 1982;50:157–164
7.Tiong Cheng Yeo, Joe F. Malouf, Jae K. Oh, James B. Seward. Clinical Profile and Outcome in 52 Patients with Cardiac Pseudoaneurysm Ann Intern Med. 1998;128:299-3
8.Gatewood RP, Nanda NC. Differentiation of left ventricular pseudoaneurysm from true aneurysm with two dimensional echocardiography. Am J Cardiol. 1980;46:869–878.
9.R Moreno, E Gordillo, J Zamorano et al. Long term outcome of patients with postinfarction left ventricular pseudoaneurysm. Heart 2003;89:1144–1146
10.Natarajan MK, Salerno TA, Burke B, et al. Chronic false aneurysm of the left ventricle: management revisited. Can J Cardiol 1994;10:927-31.
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Indian Heart J. 2010; 62:357-358