Circulation: Cardiovascular Imaging. 2008;1:171-172
doi: 10.1161/CIRCIMAGING.108.780833
Subepicardial Aneurysm Evaluated by Multiplane 2D and Real-Time 3D Volumetric Transesophageal Echocardiography
Hyun Suk Yang, MD, PhD
;
Sairav B. Shah, MD
;
John P. Sweeney, MD
;
Bijoy K. Khandheria, MD
and
Krishnaswamy Chandrasekaran, MD
From the Division of Cardiovascular Diseases, Mayo Clinic, Phoenix, AZ.
Correspondence to Krishnaswamy Chandrasekaran, MD, Professor of Medicine, Mayo College of Medicine, Division of Cardiovascular Disease, Mayo Clinic, 5777 East Mayo Boulevard, Phoenix, AZ 85054. E-mail kchandra{at}mayo.edu
A 76-year-old man with a history of hypertension, dyslipidemia, and 90 pack-year smoking, presented to his primary care physician with complaints of worsening dyspnea. His ECG finding did not show any pathological Q-wave or ST-T abnormalities (Online Figure I). A 2D transthoracic echocardiogram revealed normal left ventricular (LV) systolic function with inferior and inferolateral wall motion abnormalities. A suspicious aneurysm was also noted (Figure 1). His adenosine stress nuclear perfusion images showed a moderate-sized area of ischemia or jeopardized myocardium involving the infero-lateral LV (Online Figure II). He underwent cardiac catheterization, which revealed an occluded right coronary artery and significant left-to-right collaterals (Figure 2). Left ventriculography revealed a hypokinetic basal inferior wall and an aneurysm (Figure 3, Movie I). A follow-up transesophageal echocardiogram was performed using an x7–2t transducer on an iE33 ultrasound machine (Philips, Andover, MA) capable of both multiplane 2D and real-time 3D, which demonstrated the aneurysm within an intact epicardium (Figure 4, Movie II). This was consistent with a subepicardial aneurysm. Although the transthoracic echocardiogram and LV ventriculogram demonstrated the abnormality, the features were not distinct enough to differentiate aneurysm subtypes. However, multiplane 2D tomographic sections and the real-time 3D volumetric imaging precisely demonstrated a subepicardial aneurysm.
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Figure 1. A transthoracic echocardiogram of both end-diastolic (left panel) and end-systolic (right panel) frame reveals a focal aneurysm (arrow) at basal inferior wall. LV, left ventricle; ANT, anterior wall of LV; interferon (INF) , inferior wall of LV.
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Figure 2. The right anterior oblique (RAO 30°) view of the right coronary artery reveals a proximal high-grade diffuse stenosis and then subtotal occlusion. The distal vessels fill via left-to-right collateral from the left anterior descending and left circumflex coronary artery.
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Figure 3. A left ventriculogram in the right anterior oblique (RAO 30°) view reveals a small contrast-filled aneurismal pouch (arrows) with some hypokinesis of the basal inferior wall. LV, left ventricle, Ao, aortic root (Movie I).
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Figure 4. Multiplane 2D transesophageal echocardiogram and real-time 3D transesophageal echocardiogram volumetric images demonstrate an aneurismal pouch in the basal inferior wall of the LV, which is contained by the epicardium and some myocardial elements. A color Doppler shows a flow communication into the LV cavity. The pouch has a relatively narrow neck (maximum diameter of the neck, 6 mm; max diameter of the aneurysm pouch, 15 x 14 mm)—from the transgastric LV long axis view (A), or midesophageal 90 degree view (B) (Movie II).
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Both "true aneurysms" and "pseudoaneurysms" are out-pouching
of the LV beyond the outside contour of the chamber. The former
contains all three myocardial layers, and the latter represents
a true contained rupture of the myocardium by a blood clot with
the adjoining parietal pericardium mostly due to ischemia or
trauma. A pseudoaneurysm often needs surgical intervention to
prevent a pericardial rupture and possible sudden cardiac death.
On the other hand, a subepicardial aneurysm is an interruption
of the endocardium and myocardium with an intact epicardium.
Most often some myocardial elements are seen in the wall formed
by the epicardium.
1 The natural history of a subepicardial aneurysm
is not well described. However, conservative medical management
is considered unless there are high risk features such as a
rapid growth on surveillance imaging studies, progression to
pseudoaneurysm, or worsening symptoms.
2,3Therefore, when a ventriculogram
shows an aneurysmal pouch, echo can reveal the status of the
epicardium, which is clinically important for management. Furthermore,
cardiac MRI and, to a lesser extent, cardiac computed tomography
can demonstrate any disruption of the myocardial and pericardial
layers with greater spatial resolution.
4 Our patient did not
have any symptoms suggestive of recurrent myocardial ischemia
and his medical history, echocardiography, and coronary angiographic
findings were suggestive of a remote myocardial ischemic insult.
Hence, instead of surgery he was given aggressive medical management
with risk factor modification.
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Disclosures
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None.
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Footnotes
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The online-only Data Supplement can be found at http://circep.ahajournals.org/cgi/content/full/1/2/171/DC1
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References
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1. Bunch TJ, Oh JK, Click RL. Subepicardial aneurysm of the left ventricle.
J Am Soc Echocardiogr. 2003; 16 (12): 1318–1321.
[CrossRef][Medline]2. Koito H, Nakamura C, Suzuki J, Kamihata H, Takayama Y, Iwasaka T. Pseudoaneurysm of the left ventricle progressing from a subepicardial aneurysm. Jpn Circ J. 1999; 63 (7): 559–563.[CrossRef][Medline]
3. Gollol-Raju N, Olearczyk B, Johnson R, Menzies DJ. Pseudo-pseudoaneurysm: a rare and unexplored mechanical complication of myocardial infarction. J Am Soc Echocardiogr. 2007; 20 (11): 1317.
4. Faludi R, Toth L, Komocsi A, Varga-Szemes A, Papp L, Simor T. Chronic postinfarction pseudo-pseudoaneurysm diagnosed by cardiac MRI. J Magn Reson Imaging. 2007; 26 (6): 1656–1658.[CrossRef][Medline]
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References