Biventricular pseudoaneurysm with secondary left-to-right shunting as a rare complication of myocardial infarction: a case report

Biventricular pseudoaneurysm with secondary left-to-right shunting as a rare complication of myocardial infarction: a case report | Authorea try { document.documentElement.classList.add('js'); } catch (e) { } var _gaq = _gaq || []; _gaq.push(['_setAccount', 'G-8VDV14Y67G']); _gaq.push(['_trackPageview']); (function() { var ga = document.createElement('script'); ga.type = 'text/javascript'; ga.async = true; ga.src = ('https:' == document.location.protocol ? 'https://ssl' : 'http://www') + '.google-analytics.com/ga.js'; var s = document.getElementsByTagName('script')[0]; s.parentNode.insertBefore(ga, s); })(); Skip to main content Preprints Collections Wiley Open Research IET Open Research Ecological Society of Japan All Collections About About Authorea FAQs Contact Us Quick Search anywhere Search for preprint articles, keywords, etc. Search Search ADVANCED SEARCH SCROLL This is a preprint and has not been peer reviewed. Data may be preliminary. 30 September 2025 V1 Latest version Share on Biventricular pseudoaneurysm with secondary left-to-right shunting as a rare complication of myocardial infarction: a case report Authors : Haoyu Lu 0009-0007-9176-3810 , Ding Zhang , HuaYing Fu 0000-0002-5497-4674 , Tienan Chen , Feixue Li , Tong Liu 0000-0003-0482-0738 , and Changle Liu [email protected] Authors Info & Affiliations https://doi.org/10.22541/au.175924481.12060205/v1 126 views 99 downloads Contents Abstract Information & Authors Metrics & Citations View Options References Figures Tables Media Share Abstract Biventricular pseudoaneurysm is an infrequent complication following myocardial infarction. The diagnosis is complex and has a high risk of rupture. Transthoracic echocardiogram (TTE) and Cardiac magnetic resonance (CMR) are crucial for diagnosing. We present the case of a 79-year-old man who experienced PCI for AMI. Subsequent TTE revealed an apical pseudoaneurysm. To confirm the diagnosis and observe the progression, follow-up TTE and Cardiac-MRI were performed, confirming the pseudoaneurysm involved both ventricles with secondary left-to-right shunting. Surgical repair was performed, with postoperative TTE demonstrating the complete resolution of shunts. Biventricular pseudoaneurysm with secondary left-to-right shunting as a rare complication of myocardial infarction: a case report Haoyu Lu 1 , Ding Zhang 1 , Huaying Fu 1 , Tienan Chen 1 , Feixue Li 1 , Tong Liu 1 , Changle Liu 2* 1. The Second Hospital of Tianjin Medical University 2. The Second Hospital of Tianjin Medical University, Electronic address: [email protected] Haoyu Lu: The Second Hospital of Tianjin Medical University, [email protected] Ding Zhang: The Second Hospital of Tianjin Medical University, [email protected] Huaying Fu: The Second Hospital of Tianjin Medical University, [email protected] Tienan Chen: The Second Hospital of Tianjin Medical University, [email protected] Feixue Li: The Second Hospital of Tianjin Medical University, [email protected] Tong Liu: The Second Hospital of Tianjin Medical University, [email protected] Changle Liu: The Second Hospital of Tianjin Medical University, [email protected] Abstract Biventricular pseudoaneurysm is an infrequent complication following myocardial infarction. The diagnosis is complex and has a high risk of rupture. Transthoracic echocardiogram (TTE) and Cardiac magnetic resonance (CMR) are crucial for diagnosing. We present the case of a 79-year-old man who experienced PCI for AMI. Subsequent TTE revealed an apical pseudoaneurysm. To confirm the diagnosis and observe the progression, follow-up TTE and Cardiac-MRI were performed, confirming the pseudoaneurysm involved both ventricles with secondary left-to-right shunting. Surgical repair was performed, with postoperative TTE demonstrating the complete resolution of shunts. Keywords : Echocardiography, ventricular pseudoaneurysm, cardiovascular surgery, mechanical complications of acute myocardial infarction Case report A 79-year-old man with a history of hypertension was admitted to our hospital, complaining of severe chest pain lasting for over six hours. On admission, the electrocardiogram showed sinus rhythm, first-degree atrioventricular conduct block, pathological Q waves in V1-V5, and ST-segment elevation in the same leads. Laboratory findings revealed elevated troponin I (16.98ng/mL). Emergency coronary angiography demonstrated complete occlusion of the left anterior descending artery. After two stents were placed, blood flow improved, but there was no dynamic change in the electrocardiogram. Medical therapy included glycoprotein IIb/IIIa inhibitors, dual antiplatelet agents, intravenous nitrates, low molecular weight heparin, sacubitril/valsartan (ARNI), and recombinant human brain natriuretic peptide (rhBNP). On hospital day 3, a Grade IV holosystolic murmur was auscultated between the third and fourth ribs near the sternum. TTE identified apical dyskinesia and an apical pseudoaneurysm (5.9cm*2.5cm) originating from the left ventricular apex (Fig.1A). TTE revealed fenestrated communications (2.1cm in length) between the pseudoaneurysm and right ventricular (Fig.1B), with communication between the pseudoaneurysm and both ventricles (Fig.1C-D). The left ventricular ejection fraction (LVEF) was 47%. On hospital day 8, the repeat TTE demonstrated a left-to-right ventricular shunt (Fig.2A-B), pseudoaneurysm recurrence (diameter 2.19cm long; Fig.2C), and retrograde intramyocardial dissection (0.69cm in length) with swinging motion of the dissected ventricular septum (Fig.2D). The LVEF was 43%. CMR corroborated pseudoaneurysm morphology and tissue characteristics (Fig.3). On hospital day 14, the patient underwent surgical repair involving pseudoaneurysm resection with pericardial patch closure, bovine pericardial patch repair of the ventricular septal defect, and left ventricular plasty (Fig.4). Intraoperative findings confirmed a thin-walled pseudoaneurysm devoid of myocardial elements, consistent with contained free-wall rupture. Postoperative TTE (day 18) showed complete resolution of shunts and normalized LVEF (67%) (Fig.5). Discussion Ventricular free wall rupture following myocardial infarction is an infrequent event that usually results in rapid death. A ventricular pseudoaneurysm forms when a rupture is surrounded by fibrous tissue and pericardium but lacks myocardial elements, connecting to the ventricle by a narrow neck. Although left ventricular pseudoaneurysm is rare, biventricular pseudoaneurysm is extremely rare, and the diagnosis is difficult and has a high risk of rupture [1]. The anterior wall of the left ventricle is the most common site for these ruptures, often occurring near the septum or the base of the papillary muscle. The rupture areas are more common in the basal two-thirds of the ventricle than in the apical portion [2]. However, in this case, the pseudoaneurysm developed in the less common apical region. TTE is crucial for diagnosing acute myocardial infarction, especially when the sudden hemodynamic decline occurs due to complications like ventricular wall rupture with pseudoaneurysm or intramyocardial dissection formation [3]. In our patient, TTE revealed a sharp discontinuity in the biventricular apex myocardium at the aneurysmal orifice, a saccular contour of the aneurysmal chamber, and a relatively narrow orifice, confirming the presence of the ventricular pseudoaneurysm[4]. Furthermore, TTE confirmed anomalous blood flow from the ventricular chamber to the pseudoaneurysm. Cardiac-MRI is also vital for diagnosing the ventricular pseudoaneurysms in patients after myocardial infarction [5], showing a lack of epicardial fat near the pseudoaneurysm and a blurred pericardial line on the T1-weighted SE images [6]. Without surgical intervention, the development of a pseudoaneurysm can lead to worsening cardiac tamponade, leading to electromechanical dissociation or progressive shock [7]. In our case, the connection between the pseudoaneurysm and the biventricle may help lower the growth rate of effusion in the aneurysm, and the symptoms of pericardial tamponade were not immediately evident, delaying surgical intervention. Repairing left ventricular pseudoaneurysms can yield acceptable outcomes, although mortality rates are high in acute myocardial infarction and repeat surgeries. Unlike true aneurysms, which have a resistant fibrotic wall, pseudoaneurysms are initially made of loose tissue and are more prone to secondary rupture. Therefore, prompt surgical intervention is mandatory [8]. In summary, after an acute myocardial infarction, abnormal ST-T segment elevation and abnormal systolic murmur indicate the possibility of cardiac rupture, which should be confirmed through echocardiogram or cardiac magnetic resonance imaging, followed by timely surgical treatment. 1. Frances C, Romero A, Grady D. Left ventricular pseudoaneurysm. Journal of the American College of Cardiology . 1998;32(3):557-561. doi:10.1016/S0735-1097(98)00290-32. Lewis AJ, Burchell HB, Titus JL. Clinical and pathologic features of postinfarction cardiac rupture. Am J Cardiol . 1969;23(1):43-53. doi:10.1016/0002-9149(69)90240-93. Vargas-Barrón J, Roldán FJ, Romero-Cárdenas A, Espinola-Zavaleta N, Keirns C, González-Pacheco H. Two- and three-dimensional transesophageal echocardiographic diagnosis of intramyocardial dissecting hematoma after myocardial infarction. Journal of the American Society of Echocardiography . 2001;14(6):637-640. doi:10.1067/mje.2001.1099844. Catherwood E, Mintz GS, Kotler MN, Parry WR, Segal BL. Two-dimensional echocardiographic recognition of left ventricular pseudoaneurysm. Circulation . 1980;62(2):294-303. doi:10.1161/01.cir.62.2.2945. Ballard DH, Jokerst C, Raptis CA, Pilgram TK, Woodard PK. Myocardial Cut-Off Sign is a Sensitive and Specific Cardiac CT and MRI Sign to Distinguish Left Ventricular Pseudoaneurysms from True Aneurysms. J Thorac Imaging . 2022;37(1):58-65. doi:10.1097/RTI.00000000000005256. Duvernoy O, Wikström G, Mannting F, Larsson SG, Andrén B, Dubiel T. Pre- and postoperative CT and MR in pseudoaneurysms of the heart. J Comput Assist Tomogr . 1992;16(3):401-409. doi:10.1097/00004728-199205000-000117. Purcaro A, Costantini C, Ciampani N, et al. Diagnostic criteria and management of subacute ventricular free wall rupture complicating acute myocardial infarction. Am J Cardiol . 1997;80(4):397-405. doi:10.1016/s0002-9149(97)00385-88. Prêtre R, Linka A, Jenni R, Turina MI. Surgical treatment of acquired left ventricular pseudoaneurysms. Ann Thorac Surg . 2000;70(2):553-557. doi:10.1016/s0003-4975(00)01412-0 Fig.1 A apical dyskinesia and an apical pseudoaneurysm (5.9cm*2.5cm) originating from the left ventricular apex. B fenestrated communications (2.1cm in length) between the pseudoaneurysm and the right ventricular. C and D blood flows into the pseudoaneurysm from both ventricular sides. Fig.2 A and B: a left-to-right ventricular shunt. C pseudoaneurysm recurrence (diameter 2.19cm long). D retrograde intramyocardial dissection (0.69cm in length) with swinging motion of the dissected ventricular septum. Fig.3 Cardiac-MRI demonstrated the pseudoaneurysm. Fig.4 Surgical repair involving pseudoaneurysm resection with pericardial patch closure, bovine pericardial patch repair of the ventricular septal defect, and left ventricular plasty. Fig.5 TTE demonstrated the resolution of shunts Information & Authors Information Version history V1 Version 1 30 September 2025 Copyright This work is licensed under a Non Exclusive No Reuse License. Keywords cardiovascularsurgery echocardiography mechanical complications of acute myocardial infarction ventricular pseudoaneurysm Authors Affiliations Haoyu Lu 0009-0007-9176-3810 The Second Hospital of Tianjin Medical University View all articles by this author Ding Zhang The Second Hospital of Tianjin Medical University View all articles by this author HuaYing Fu 0000-0002-5497-4674 The Second Hospital of Tianjin Medical University View all articles by this author Tienan Chen The Second Hospital of Tianjin Medical University View all articles by this author Feixue Li The Second Hospital of Tianjin Medical University View all articles by this author Tong Liu 0000-0003-0482-0738 The Second Hospital of Tianjin Medical University View all articles by this author Changle Liu [email protected] The Second Hospital of Tianjin Medical University View all articles by this author Metrics & Citations Metrics Article Usage 126 views 99 downloads .FvxKWukQNSOunydq8rnd { width: 100px; } Citations Download citation Haoyu Lu, Ding Zhang, HuaYing Fu, et al. Biventricular pseudoaneurysm with secondary left-to-right shunting as a rare complication of myocardial infarction: a case report. Authorea . 30 September 2025. DOI: https://doi.org/10.22541/au.175924481.12060205/v1 If you have the appropriate software installed, you can download article citation data to the citation manager of your choice. Simply select your manager software from the list below and click Download. For more information or tips please see 'Downloading to a citation manager' in the Help menu . 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