Case report
Giant left ventricular pseudoaneurysm: The diagnostic contribution of different non-invasive imaging modalities
Pseudoaneurisma gigante do ventrículo esquerdo: contributo diagnóstico de diferentes modalidades de imagem não invasivas
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Madureira, Paulo Pinho, Isabel Ramos, Maria Júlia Maciel" "autores" => array:9 [ 0 => array:4 [ "nombre" => "Sílvia Marta" "apellidos" => "Oliveira" "email" => array:1 [ 0 => "silviamartaoliveira@yahoo.co.uk" ] "referencia" => array:3 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] 2 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">¿</span>" "identificador" => "cor0005" ] ] ] 1 => array:3 [ "nombre" => "Paula" "apellidos" => "Dias" "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] 2 => array:3 [ "nombre" => "Teresa" "apellidos" => "Pinho" "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] 3 => array:3 [ "nombre" => "Cristina" "apellidos" => "Gavina" "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] 4 => array:3 [ "nombre" => "Pedro Bernardo" "apellidos" => "Almeida" "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] 5 => array:3 [ "nombre" => "António J." "apellidos" => "Madureira" "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">c</span>" "identificador" => "aff0015" ] ] ] 6 => array:3 [ "nombre" => "Paulo" "apellidos" => "Pinho" "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">d</span>" "identificador" => "aff0020" ] ] ] 7 => array:3 [ "nombre" => "Isabel" "apellidos" => "Ramos" "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">c</span>" "identificador" => "aff0015" ] ] ] 8 => array:3 [ "nombre" => "Maria Júlia" "apellidos" => "Maciel" "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] ] "afiliaciones" => array:4 [ 0 => array:3 [ "entidad" => "Serviço de Cardiologia, Hospital de São João, Porto, Portugal" "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Faculdade de Medicina da Universidade do Porto, Porto, Portugal" "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] 2 => array:3 [ "entidad" => "Serviço de Radiologia, Hospital de São João, Porto, Portugal" "etiqueta" => "<span class="elsevierStyleSup">c</span>" "identificador" => "aff0015" ] 3 => array:3 [ "entidad" => "Serviço de Cirurgia Cardio-Torácica, Hospital de São João, Porto, Portugal" "etiqueta" => "<span class="elsevierStyleSup">d</span>" "identificador" => "aff0020" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "pt" => array:1 [ "titulo" => "Pseudoaneurisma gigante do ventrículo esquerdo: contributo diagnóstico de diferentes modalidades de imagem não invasivas" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0020" "etiqueta" => "Figure 4" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr4.jpeg" "Alto" => 1590 "Ancho" => 2333 "Tamanyo" => 199653 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Two-dimensional echocardiogram, in apical 4-chamber (A), short-axis (B), 2-chamber (C) and subcostal (D) views, showing a left ventricular pseudoaneurysm (Ps), with a narrow neck (arrow) extending infero-posteriorly and compressing the right ventricle (VD).</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">The advent of early myocardial revascularization has led to a reduction in the incidence of mechanical complications after myocardial infarction (MI). Nevertheless, left ventricular (LV) free wall rupture, one of the most feared complications, occurs in 4% of MI patients, and is responsible for around a quarter of related deaths.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> In rare cases, the rupture is contained by adherent pericardium, giving rise to a cavity delineated by scar tissue but with no muscle fibers, producing what has been termed a pseudoaneurysm; the risk of rupture is thus high<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> and urgent surgical repair is necessary. Given the prognostic and therapeutic implications, prompt diagnosis is essential. However, there are no features of clinical presentation, physical examination, chest X-ray or electrocardiogram (ECG) that are sensitive and specific to ventricular pseudoaneurysms as opposed to true aneurysms, which are a more common complication of MI. The present case illustrates these difficulties in diagnosis and highlights the role of imaging techniques in identifying this entity.<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a></p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Case report</span><p id="par0010" class="elsevierStylePara elsevierViewall">We report the case of a 72-year-old man, white, an ex-smoker, with a history of transurethral prostatectomy and cerebrovascular disease. He was not taking any cardiovascular medication. In February 2009, he suffered prolonged crushing chest pain radiating to the back accompanied by vomiting, but did not seek medical attention. He then began experiencing heart failure symptoms, with progressively worsening exertional dyspnea, but without recurrence of chest pain. Approximately one month later, he came to the emergency department of our hospital due to worsening symptoms, and was found to be in New York Heart Association (NYHA) class IV. The admission ECG showed signs of a previous anterior MI; no elevation of myocardial necrosis markers was observed. Echocardiographic assessment revealed severe LV systolic dysfunction, an apical aneurysm with intense auto-contrast (<a class="elsevierStyleCrossRef" href="#fig0005">Figure 1</a>) and a sessile thrombus; oral anticoagulation was therefore initiated.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0015" class="elsevierStylePara elsevierViewall">Due to suspicion of pulmonary tuberculosis and marked deterioration in the patient's general condition, non-invasive stratification was the initial approach adopted. Further studies during hospitalization in the internal medicine department revealed no microbiological agent in bronchial secretions, gastric juice or blood cultures. There was a progressive fall in markers of systemic inflammation, obviating the need for empirical antibiotic therapy. The patient was discharged three weeks later, and referred for outpatient consultation. Some months later, he was rehospitalized for worsening heart failure.</p><p id="par0020" class="elsevierStylePara elsevierViewall">The ECG showed signs of a previous MI (<a class="elsevierStyleCrossRef" href="#fig0010">Figure 2</a>) and the chest X-ray revealed a mass adjacent to the cardiac silhouette (<a class="elsevierStyleCrossRef" href="#fig0015">Figure 3</a>). Repeat echocardiography showed a large apical aneurysm, the image being compatible with a pseudoaneurysm, extending infero-posteriorly and compressing the right ventricle (<a class="elsevierStyleCrossRef" href="#fig0020">Figure 4</a>).</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><elsevierMultimedia ident="fig0015"></elsevierMultimedia><elsevierMultimedia ident="fig0020"></elsevierMultimedia><p id="par0025" class="elsevierStylePara elsevierViewall">These findings prompted reversal of oral anticoagulation and suspension of antiplatelet therapy. Cardiac magnetic resonance imaging (CMRI) was performed to clarify the anatomy and aid the planning of surgical repair, which confirmed the presence of a large pseudoaneurysm and showed its extension and close relation to the right ventricle, which was subject to significant compression. Delayed enhancement study was able to define the extent of the infarct and documented the presence of viable myocardium in the mid-basal segments of the left ventricle (<a class="elsevierStyleCrossRef" href="#fig0025">Figure 5</a>).</p><elsevierMultimedia ident="fig0025"></elsevierMultimedia><p id="par0030" class="elsevierStylePara elsevierViewall">Following coronary angiography that showed occlusion of the mid segment of the anterior descending and 60% stenosis of the right coronary artery, the pseudoaneurysm was surgically resected, the LV aneurysm was excluded and the ventricle was reconstructed (Dor procedure) (<a class="elsevierStyleCrossRef" href="#fig0030">Figure 6</a>).</p><elsevierMultimedia ident="fig0030"></elsevierMultimedia><p id="par0035" class="elsevierStylePara elsevierViewall">The patient's recovery was initially slow, but following discharge he has remained clinically stable, in NYHA class II. Repeat echocardiography three months after the surgical intervention showed normal LV dimensions, mildly impaired global systolic function, and a correctly positioned ventricular patch (<a class="elsevierStyleCrossRef" href="#fig0035">Figure 7</a>).</p><elsevierMultimedia ident="fig0035"></elsevierMultimedia></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Discussion</span><p id="par0040" class="elsevierStylePara elsevierViewall">Mechanical complications after MI are now much less frequent following implementation of effective early revascularization strategies. Although infrequent, cardiac rupture is one of the most feared events since it is almost always fatal. In rare cases, the rupture may be contained by adherent pericardium or scar tissue, giving rise to a saccular formation with no myocardial fibers, which is termed a pseudoaneurysm. Given the composition of its wall, there is a high risk of expansion and rupture,<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> and urgent surgical repair is thus required. By contrast, a true aneurysm represents extreme maladaptive remodeling following an ischemic event. It consists of an area of thinned ventricular wall, still with three layers, that moves dyskinetically but has a low risk of rupture; it is therefore usually treated conservatively.</p><p id="par0045" class="elsevierStylePara elsevierViewall">Occasionally, the two entities coexist,<a class="elsevierStyleCrossRefs" href="#bib0020"><span class="elsevierStyleSup">4,5</span></a> or a ventricular aneurysm can be complicated by rupture,<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3,6</span></a> as may have occurred in the case presented. Given the prognostic and therapeutic implications, a correct and prompt diagnosis of pseudoaneurysm is essential.</p><p id="par0050" class="elsevierStylePara elsevierViewall">From a clinical standpoint, patients may be asymptomatic (up to 48% of cases<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a>) or present with recurrent chest pain, signs of heart failure, syncope or thromboembolic phenomena.<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2,8</span></a> Sudden death is the form of presentation of ventricular pseudoaneurysm in only 3% of cases.<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a></p><p id="par0055" class="elsevierStylePara elsevierViewall">Physical examination is of little value, usually only showing soft heart sounds, pericardial friction rub or <span class="elsevierStyleItalic">de novo</span> murmurs.</p><p id="par0060" class="elsevierStylePara elsevierViewall">There are ECG alterations in most cases, with pathological Q waves or persistent ST-segment elevation in the infarct-related leads. In more than half of cases, the chest X-ray shows cardiomegaly and/or a mass adjacent to the cardiac silhouette, as seen in <a class="elsevierStyleCrossRef" href="#fig0015">Figure 3</a>. Nevertheless, while common, these findings are not specific, and cannot identify a pseudoaneurysm or differentiate between this and a true ventricular aneurysm. Cardiac imaging modalities thus play a pivotal role in characterizing this entity.</p><p id="par0065" class="elsevierStylePara elsevierViewall">Transthoracic echocardiography, a readily available non-invasive imaging technique, is commonly used for the initial assessment of patients with MI, and helps not only with diagnosis, but also with determining the location and extent of the infarct, identifying mechanical complications and providing information that helps in stratifying risk and prognosis. Nevertheless, differential diagnosis between ventricular pseudoaneurysms and true aneurysms based on echocardiographic findings is a challenge. Inferior, posterior or lateral location,<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> a ratio of <0.5 between the width of the neck and the maximal internal diameter of the aneurysmal sac,<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a> or the presence of bidirectional turbulent flow through the neck by color and pulsed Doppler study,<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a> are all suggestive of pseudoaneurysm, but such findings are limited in terms of sensitivity and specificity.<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2,3</span></a> According to Frances et al., in a series of 290 patients with ventricular pseudoaneurysm, transthoracic echocardiography enabled a definitive diagnosis in up to a third of cases.<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> Diagnostic accuracy can be improved by using transesophageal echocardiography (accuracy of over 75%) or contrast agents that enable enhanced endocardial border delineation and identification of distortion of normal ventricular geometry such as a pseudoaneurysm.<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">11</span></a></p><p id="par0070" class="elsevierStylePara elsevierViewall">Left ventriculography is considered the gold standard imaging modality, with diagnostic accuracy of around 85%.<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> The characteristic angiographic features of ventricular pseudoaneurysm are a narrow-necked aneurysmal sac with no adjacent coronary vessels in which contrast liquid remains for several cardiac cycles after injection.<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">12</span></a> Furthermore, cardiac catheterization enables detection and characterization of associated coronary disease, valve disease (particularly mitral), and pulmonary hypertension, and thus helps in planning surgical treatment. However, it is an invasive technique that exposes the patient to ionizing radiation and presents a real risk of possible embolization of thrombotic material.</p><p id="par0075" class="elsevierStylePara elsevierViewall">Recent advances have enabled computed tomography (CT) to be used for non-invasive coronary assessment as well as the acquisition of three-dimensional anatomical and functional information on the myocardium and pericardium. An interruption in the continuity of the endocardial outline, resulting in a narrow-necked aneurysmal sac with pulsatile flow, indicates a diagnosis of ventricular pseudoaneurysm.<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">13</span></a> However, the fact that CT is not readily available, has limited temporal resolution, requires the use of iodinated contrast and exposes the patient to ionizing radiation, makes the technique a second-line option in this context.<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">14</span></a></p><p id="par0080" class="elsevierStylePara elsevierViewall">CMRI has been used since 1991 to improve diagnosis of ventricular pseudoaneurysms.<a class="elsevierStyleCrossRefs" href="#bib0075"><span class="elsevierStyleSup">15,16</span></a> This technique has high spatial resolution and the ability to characterize tissue, thus enabling non-invasive identification of the pericardium and the presence of thrombi, and can distinguish between necrotic and normal myocardium, which is not always possible with other imaging modalities. Besides providing information on overall morphology and function, particularly ventricular volumes and systolic and valve function, CMRI provides better morphological definition of a pseudoaneurysm's location, extension and its relations to adjacent structures. Moreover, delayed enhancement sequences enable accurate assessment of the location and extent of the infarcted area and of viable myocardium, thus contributing to pre-operative planning. Pericardial delayed enhancement (not only bordering the false cavity but in areas surrounding normal myocardium) has been proposed as a useful method of distinguishing between pseudoaneurysm and true ventricular aneurysm, with a sensitivity of 100% and specificity of 83%.<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">17</span></a> It is considered to reflect pericardial inflammation and fibrosis arising from the seepage of blood into the pericardial space at the time of rupture.<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">16</span></a></p><p id="par0085" class="elsevierStylePara elsevierViewall">Given its many advantages, CMRI has great appeal as an imaging modality, with enormous potential to differentiate between ventricular aneurysms and pseudoaneurysms. In view of its growing availability and advances in acquisition sequences, the technique is increasingly used in clinical practice, even in relatively unstable patients, as in the case presented. It has added diagnostic value over echocardiography, particularly in patients with poor image quality, and is able to accurately assess the extent of the infarcted area and the number of viable segments, as well as to determine the relations of the pseudoaneurysm to the mitral valve and papillary muscles. Such an assessment is crucial to planning the surgical technique to adopt, which in most cases will be conventional surgical repair, but can mean heart transplantation in selected cases.</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Conclusions</span><p id="par0090" class="elsevierStylePara elsevierViewall">Differential diagnosis between aneurysm and pseudoaneurysm is particularly difficult but of major importance due to the therapeutic and prognostic implications. Improvements in the resolution of non-invasive cardiac imaging modalities have contributed to more accurate and prompt diagnoses, ensuring appropriate management of these patients.</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Conflicts of interest</span><p id="par0095" class="elsevierStylePara elsevierViewall">The authors have no conflicts of interest to declare.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:10 [ 0 => array:2 [ "identificador" => "xres176232" "titulo" => "Abstract" ] 1 => array:2 [ "identificador" => "xpalclavsec164602" "titulo" => "Keywords" ] 2 => array:2 [ "identificador" => "xres176233" "titulo" => "Resumo" ] 3 => array:2 [ "identificador" => "xpalclavsec164601" "titulo" => "Palavras-chave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:2 [ "identificador" => "sec0010" "titulo" => "Case report" ] 6 => array:2 [ "identificador" => "sec0015" "titulo" => "Discussion" ] 7 => array:2 [ "identificador" => "sec0020" "titulo" => "Conclusions" ] 8 => array:2 [ "identificador" => "sec0025" "titulo" => "Conflicts of interest" ] 9 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2011-07-08" "fechaAceptado" => "2011-11-04" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec164602" "palabras" => array:5 [ 0 => "Pseudoaneurysm" 1 => "Left ventricle" 2 => "Echocardiography" 3 => "Cardiac magnetic resonance" 4 => "Left ventricular reconstructive surgery" ] ] ] "pt" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palavras-chave" "identificador" => "xpalclavsec164601" "palabras" => array:5 [ 0 => "Pseudoaneurisma" 1 => "Ventrículo esquerdo" 2 => "Ecocardiografia" 3 => "Ressonância magnética cardíaca" 4 => "Cirurgia de reconstrução ventricular" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:2 [ "titulo" => "Abstract" "resumen" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Distinguishing between zventricular aneurysm and pseudoaneurysm, although difficult, is of major importance due to the therapeutic and prognostic implications. The present case highlights the pivotal role of non-invasive imaging modalities for differential diagnosis between these entities in order to ensure appropriate management of these patients.</p>" ] "pt" => array:2 [ "titulo" => "Resumo" "resumen" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">O diagnóstico diferencial entre o aneurisma e o pseudoaneurisma ventricular, embora difícil, é fundamental face às implicações terapêutica e prognóstica. O presente caso clínico realça o papel fulcral das técnicas de imagem não invasivas no diagnóstico diferencial destas entidades, possibilitando uma correta orientação dos doentes.</p>" ] ] "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara">Please cite this article as: Oliveira S, et al. Pseudoaneurisma gigante do ventrículo esquerdo: contributo diagnóstico de diferentes modalidades de imagem não invasivas. Rev Port Cardiol. 2012. <span class="elsevierStyleInterRef" href="doi:10.1016/j.repc.2012.04.009">doi:10.1016/j.repc.2012.04.009</span>.</p>" ] ] "multimedia" => array:7 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1885 "Ancho" => 1583 "Tamanyo" => 155049 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Two-dimensional echocardiogram in diastole, apical 4-chamber view (left) and apical 2-chamber color Doppler (right), showing a wide-necked apical aneurysm with auto-contrast in the left ventricle.</p>" ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 1362 "Ancho" => 3167 "Tamanyo" => 519104 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">12-lead electrocardiogram showing signs of non-recent anterior and inferior myocardial infarction and persistence of ST-segment elevation in V2–V4.</p>" ] ] 2 => array:7 [ "identificador" => "fig0015" "etiqueta" => "Figure 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 1542 "Ancho" => 1583 "Tamanyo" => 131716 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Chest X-ray showing cardiomegaly and a radio-opaque mass next to the left border of the cardiac silhouette (arrow).</p>" ] ] 3 => array:7 [ "identificador" => "fig0020" "etiqueta" => "Figure 4" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr4.jpeg" "Alto" => 1590 "Ancho" => 2333 "Tamanyo" => 199653 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Two-dimensional echocardiogram, in apical 4-chamber (A), short-axis (B), 2-chamber (C) and subcostal (D) views, showing a left ventricular pseudoaneurysm (Ps), with a narrow neck (arrow) extending infero-posteriorly and compressing the right ventricle (VD).</p>" ] ] 4 => array:7 [ "identificador" => "fig0025" "etiqueta" => "Figure 5" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr5.jpeg" "Alto" => 806 "Ancho" => 2667 "Tamanyo" => 176504 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Cardiac magnetic resonance imaging, steady-state free precession sequences in vertical long-axis (A) and 4-chamber (B) views, confirming the presence of a large left ventricular pseudoaneurysm. Delayed enhancement images (phase-sensitive inversion recovery) acquired 10<span class="elsevierStyleHsp" style=""></span>minutes after administration of gadolinium, in 4-chamber view (C), show a transmural area of contrast uptake surrounding the aneurysm (arrows).</p>" ] ] 5 => array:7 [ "identificador" => "fig0030" "etiqueta" => "Figure 6" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr6.jpeg" "Alto" => 662 "Ancho" => 2667 "Tamanyo" => 263798 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">Intra-operative images showing the entry point of the pseudoaneurysm (A) and the resected aneurysm (B). The patient subsequently underwent ventricular reconstruction (Dor procedure) (C).</p>" ] ] 6 => array:7 [ "identificador" => "fig0035" "etiqueta" => "Figure 7" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr7.jpeg" "Alto" => 932 "Ancho" => 2642 "Tamanyo" => 151345 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Two-dimensional transesophageal echocardiography, short-axis views in systole (A) and diastole (B) and 4-chamber view in diastole (C), showing a left ventricle of normal dimensions, mildly impaired systolic function and a correctly positioned ventricular patch, with no evidence of leakage.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:17 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Distinguishing left ventricular aneurysm from pseudoaneurysm. 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| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 6 | 8 | 14 |
| 2024 October | 47 | 32 | 79 |
| 2024 September | 78 | 32 | 110 |
| 2024 August | 72 | 33 | 105 |
| 2024 July | 49 | 38 | 87 |
| 2024 June | 40 | 25 | 65 |
| 2024 May | 50 | 19 | 69 |
| 2024 April | 54 | 33 | 87 |
| 2024 March | 59 | 21 | 80 |
| 2024 February | 44 | 20 | 64 |
| 2024 January | 63 | 21 | 84 |
| 2023 December | 51 | 30 | 81 |
| 2023 November | 61 | 25 | 86 |
| 2023 October | 50 | 18 | 68 |
| 2023 September | 51 | 22 | 73 |
| 2023 August | 50 | 13 | 63 |
| 2023 July | 59 | 10 | 69 |
| 2023 June | 52 | 15 | 67 |
| 2023 May | 87 | 27 | 114 |
| 2023 April | 73 | 2 | 75 |
| 2023 March | 57 | 17 | 74 |
| 2023 February | 56 | 30 | 86 |
| 2023 January | 59 | 15 | 74 |
| 2022 December | 73 | 19 | 92 |
| 2022 November | 82 | 29 | 111 |
| 2022 October | 60 | 28 | 88 |
| 2022 September | 50 | 22 | 72 |
| 2022 August | 51 | 34 | 85 |
| 2022 July | 60 | 31 | 91 |
| 2022 June | 56 | 23 | 79 |
| 2022 May | 54 | 29 | 83 |
| 2022 April | 64 | 29 | 93 |
| 2022 March | 48 | 27 | 75 |
| 2022 February | 61 | 29 | 90 |
| 2022 January | 74 | 32 | 106 |
| 2021 December | 40 | 30 | 70 |
| 2021 November | 55 | 34 | 89 |
| 2021 October | 65 | 47 | 112 |
| 2021 September | 57 | 25 | 82 |
| 2021 August | 57 | 29 | 86 |
| 2021 July | 45 | 29 | 74 |
| 2021 June | 46 | 18 | 64 |
| 2021 May | 49 | 54 | 103 |
| 2021 April | 91 | 37 | 128 |
| 2021 March | 123 | 24 | 147 |
| 2021 February | 72 | 23 | 95 |
| 2021 January | 46 | 19 | 65 |
| 2020 December | 57 | 12 | 69 |
| 2020 November | 67 | 28 | 95 |
| 2020 October | 77 | 21 | 98 |
| 2020 September | 75 | 32 | 107 |
| 2020 August | 39 | 7 | 46 |
| 2020 July | 83 | 11 | 94 |
| 2020 June | 43 | 15 | 58 |
| 2020 May | 68 | 1 | 69 |
| 2020 April | 83 | 15 | 98 |
| 2020 March | 43 | 3 | 46 |
| 2020 February | 121 | 17 | 138 |
| 2020 January | 58 | 11 | 69 |
| 2019 December | 56 | 3 | 59 |
| 2019 November | 62 | 8 | 70 |
| 2019 October | 24 | 6 | 30 |
| 2019 September | 53 | 5 | 58 |
| 2019 August | 47 | 4 | 51 |
| 2019 July | 50 | 10 | 60 |
| 2019 June | 42 | 12 | 54 |
| 2019 May | 43 | 9 | 52 |
| 2019 April | 35 | 14 | 49 |
| 2019 March | 95 | 16 | 111 |
| 2019 February | 87 | 10 | 97 |
| 2019 January | 88 | 10 | 98 |
| 2018 December | 96 | 17 | 113 |
| 2018 November | 123 | 15 | 138 |
| 2018 October | 245 | 17 | 262 |
| 2018 September | 95 | 17 | 112 |
| 2018 August | 70 | 7 | 77 |
| 2018 July | 40 | 2 | 42 |
| 2018 June | 40 | 4 | 44 |
| 2018 May | 45 | 6 | 51 |
| 2018 April | 55 | 4 | 59 |
| 2018 March | 74 | 6 | 80 |
| 2018 February | 22 | 7 | 29 |
| 2018 January | 31 | 5 | 36 |
| 2017 December | 75 | 5 | 80 |
| 2017 November | 55 | 7 | 62 |
| 2017 October | 61 | 8 | 69 |
| 2017 September | 57 | 5 | 62 |
| 2017 August | 76 | 6 | 82 |
| 2017 July | 95 | 5 | 100 |
| 2017 June | 100 | 12 | 112 |
| 2017 May | 138 | 25 | 163 |
| 2017 April | 83 | 50 | 133 |
| 2017 March | 195 | 12 | 207 |
| 2017 February | 103 | 6 | 109 |
| 2017 January | 62 | 7 | 69 |
| 2016 December | 62 | 15 | 77 |
| 2016 November | 76 | 9 | 85 |
| 2016 October | 62 | 5 | 67 |
| 2016 September | 53 | 7 | 60 |
| 2016 August | 25 | 2 | 27 |
| 2016 July | 28 | 6 | 34 |
| 2016 June | 17 | 10 | 27 |
| 2016 May | 31 | 3 | 34 |
| 2016 April | 68 | 2 | 70 |
| 2016 March | 96 | 10 | 106 |
| 2016 February | 132 | 19 | 151 |
| 2016 January | 101 | 23 | 124 |
| 2015 December | 116 | 12 | 128 |
| 2015 November | 100 | 12 | 112 |
| 2015 October | 125 | 16 | 141 |
| 2015 September | 112 | 13 | 125 |
| 2015 August | 83 | 12 | 95 |
| 2015 July | 179 | 7 | 186 |
| 2015 June | 123 | 7 | 130 |
| 2015 May | 103 | 12 | 115 |
| 2015 April | 89 | 13 | 102 |
| 2015 March | 98 | 5 | 103 |
| 2015 February | 231 | 9 | 240 |
| 2015 January | 92 | 9 | 101 |
| 2014 December | 114 | 8 | 122 |
| 2014 November | 93 | 12 | 105 |
| 2014 October | 99 | 13 | 112 |
| 2014 September | 116 | 15 | 131 |
| 2014 August | 95 | 11 | 106 |
| 2014 July | 92 | 11 | 103 |
| 2014 June | 79 | 7 | 86 |
| 2014 May | 84 | 9 | 93 |
| 2014 April | 114 | 6 | 120 |
| 2014 March | 138 | 20 | 158 |
| 2014 February | 130 | 14 | 144 |
| 2014 January | 138 | 17 | 155 |
| 2013 December | 119 | 14 | 133 |
| 2013 November | 121 | 23 | 144 |
| 2013 October | 134 | 19 | 153 |
| 2013 September | 102 | 18 | 120 |
| 2013 August | 138 | 26 | 164 |
| 2013 July | 123 | 18 | 141 |
| 2013 June | 77 | 15 | 92 |
| 2013 May | 110 | 16 | 126 |
| 2013 April | 116 | 29 | 145 |
| 2013 March | 93 | 18 | 111 |
| 2013 February | 72 | 24 | 96 |
| 2013 January | 103 | 28 | 131 |
| 2012 December | 113 | 18 | 131 |
| 2012 November | 96 | 18 | 114 |
| 2012 October | 70 | 18 | 88 |
| 2012 September | 49 | 4 | 53 |
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