Multiple left ventricular aneurysms in a young female | Revista Portuguesa de Cardiologia (English edition)

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(A) Bright-blood image showing apical aneurysm (white arrow) and submitral aneurysm (red arrow) in vertical long-axis view; (B) bright-blood image showing apical aneurysm (white arrow) and anterior aneurysm (yellow arrow) in 4-chamber view." ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "Abhishek P. Raval, Anand Shukla, Rajiv Garg, Yashpal Rana, Komal Shah" "autores" => array:5 [ 0 => array:2 [ "nombre" => "Abhishek P." 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(A) Apical 4-chamber view showing large pseudoaneurysm (asterisk) with neck (long arrow) 14 mm wide; (B) apical long-axis view with color Doppler showing turbulent flow across the defect (small arrow)." ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "Tarun Madan, Manish Juneja, Abhishek Raval, Bhavesh Thakkar" "autores" => array:4 [ 0 => array:2 [ "nombre" => "Tarun" "apellidos" => "Madan" ] 1 => array:2 [ "nombre" => "Manish" "apellidos" => "Juneja" ] 2 => array:2 [ "nombre" => "Abhishek" "apellidos" => "Raval" ] 3 => array:2 [ "nombre" => "Bhavesh" "apellidos" => "Thakkar" ] ] ] ] ] "idiomaDefecto" => "en" "Traduccion" => array:1 [ "en" => array:9 [ "pii" => "S0870255116000056" "doi" => "10.1016/j.repc.2015.06.013" "estado" => "S300" "subdocumento" => "" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:1 [ "total" => 0 ] "idiomaDefecto" => "en" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0870255116000056?idApp=UINPBA00004E" ] ] "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2174204916000295?idApp=UINPBA00004E" "url" => "/21742049/0000003500000002/v2_201703220311/S2174204916000295/v2_201703220311/en/main.assets" ] "itemAnterior" => array:19 [ "pii" => "S2174204916000271" "issn" => "21742049" "doi" => "10.1016/j.repce.2015.09.010" "estado" => "S300" "fechaPublicacion" => "2016-02-01" "aid" => "757" "copyright" => "Sociedade Portuguesa de Cardiologia" "documento" => "article" "crossmark" => 1 "licencia" => "http://creativecommons.org/licenses/by-nc-nd/4.0/" "subdocumento" => "ssu" "cita" => "Rev Port Cardiol. 2016;35:105-12" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:2 [ "total" => 4684 "formatos" => array:3 [ "EPUB" => 166 "HTML" => 3990 "PDF" => 528 ] ] "en" => array:13 [ "idiomaDefecto" => true "cabecera" => "Review article" "titulo" => "Coronary optical coherence tomography: A practical overview of current clinical applications" "tienePdf" => "en" "tieneTextoCompleto" => "en" "tieneResumen" => array:2 [ 0 => "en" 1 => "pt" ] "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "105" "paginaFinal" => "112" ] ] "titulosAlternativos" => array:1 [ "pt" => array:1 [ "titulo" => "Tomografia de coerência ótica coronária: uma revisão prática das aplicações clínicas atuais" ] ] "contieneResumen" => array:2 [ "en" => true "pt" => true ] "contieneTextoCompleto" => array:1 [ "en" => true ] "contienePdf" => array:1 [ "en" => true ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 1229 "Ancho" => 3169 "Tamanyo" => 571377 ] ] "descripcion" => array:1 [ "en" => "(A–C) Optical coherence tomography showing a large spontaneous ulceration in the circumflex artery." ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "Rui Cruz Ferreira, Tiago Pereira-da-Silva, Lino Patrício, Hiram Bezerra, Marco Costa" "autores" => array:5 [ 0 => array:2 [ "nombre" => "Rui" "apellidos" => "Cruz Ferreira" ] 1 => array:2 [ "nombre" => "Tiago" "apellidos" => "Pereira-da-Silva" ] 2 => array:2 [ "nombre" => "Lino" "apellidos" => "Patrício" ] 3 => array:2 [ "nombre" => "Hiram" "apellidos" => "Bezerra" ] 4 => array:2 [ "nombre" => "Marco" "apellidos" => "Costa" ] ] ] ] ] "idiomaDefecto" => "en" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2174204916000271?idApp=UINPBA00004E" "url" => "/21742049/0000003500000002/v2_201703220311/S2174204916000271/v2_201703220311/en/main.assets" ] "en" => array:19 [ "idiomaDefecto" => true "cabecera" => "Case report" "titulo" => "Multiple left ventricular aneurysms in a young female" "tieneTextoCompleto" => true "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "113.e1" "paginaFinal" => "113.e6" ] ] "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "Abhishek P. Raval, Anand Shukla, Rajiv Garg, Yashpal Rana, Komal Shah" "autores" => array:5 [ 0 => array:4 [ "nombre" => "Abhishek P." "apellidos" => "Raval" "email" => array:1 [ 0 => "docabs4u@gmail.com" ] "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "*" "identificador" => "cor0005" ] ] ] 1 => array:2 [ "nombre" => "Anand" "apellidos" => "Shukla" ] 2 => array:2 [ "nombre" => "Rajiv" "apellidos" => "Garg" ] 3 => array:2 [ "nombre" => "Yashpal" "apellidos" => "Rana" ] 4 => array:2 [ "nombre" => "Komal" "apellidos" => "Shah" ] ] "afiliaciones" => array:1 [ 0 => array:2 [ "entidad" => "U.N. Mehta Institute of Cardiology and Research Centre (UNMICRC), Ahmedabad, India" "identificador" => "aff0005" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "pt" => array:1 [ "titulo" => "Múltiplos aneurismas do ventrículo esquerdo numa jovem" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 3264 "Ancho" => 2374 "Tamanyo" => 675419 ] ] "descripcion" => array:1 [ "en" => "Transthoracic two-dimensional echocardiogram with color Doppler. (A) Apical 4-chamber view in systole showing apical aneurysm (*); (B) parasternal long-axis view in diastole showing submitral aneurysm (**)." ] ] ] "textoCompleto" => "IntroductionLeft ventricular aneurysm (LVA) is usually defined as a segment of the ventricular wall that exhibits paradoxical systolic expansion; the term is generally reserved for a discrete, dyskinetic area of the left ventricular (LV) wall with a broad neck.<a class="elsevierStyleCrossRefs" href="#bib0190">1,2</a> It most frequently develops after myocardial infarction (MI).<a class="elsevierStyleCrossRef" href="#bib0200">3</a> However, other causes may be infectious, inflammatory, metabolic or autoimmune in nature. Multiple idiopathic LVAs are distinctly unusual and rarely reported. The clinical spectrum ranges from asymptomatic to congestive heart failure (CHF) to life-threatening ventricular arrhythmias and cardiac arrest.<a class="elsevierStyleCrossRefs" href="#bib0200">3,4</a> Herein, we report the case of a young female with multiple large LVAs, managed conservatively in the absence of overt CHF, arrhythmias and embolism, with excellent outcome.Case reportA 29-year-old woman presented with easy fatigability and chest discomfort for several months. These symptoms were insidious in onset and progressed little. There was no history of palpitations, syncope or dyspnea. She was hemodynamically stable with diffuse apex beat shifted downward and outward. The chest radiograph showed calcified LV apical and basal aneurysms. The electrocardiogram showed no pathological Q waves and normal precordial R-wave progression (<a class="elsevierStyleCrossRef" href="#fig0005">Figure 1</a>). Two-dimensional transthoracic echocardiography (iE33 xMATRIX, Philips Healthcare, Andover, MA, USA) showed moderate LV dysfunction; multiple LVAs (large apical aneurysm, moderate sized submitral aneurysm, and basal anterior aneurysm); normal contractility of the rest of the LV wall; and normal valves, other chambers and great vessels (<a class="elsevierStyleCrossRef" href="#fig0010">Figure 2</a>). The echocardiogram showed continuity of the myocardium of the aneurysms with the rest of the myocardium. Color flow Doppler showed flow in and out of the aneurysms.<elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia>The coronary angiogram (Philips Medical Systems, Nederland B.V.) showed normal epicardial coronaries. Catheterization showed LV pressure of 114/3 mmHg. Systemic and pulmonary arterial, right atrial and ventricular pressures were also normal. The left ventriculogram showed a large LV apical aneurysm with a heavily calcified thrombosed distal part, a large aneurysm of the basal anterior wall with a smooth and calcified distal part, and a moderate sized submitral aneurysm. All the aneurysms had large necks, poor contractility and paradoxical systolic filling. Contrast clearance was slightly delayed by a beat (<a class="elsevierStyleCrossRef" href="#fig0015">Figure 3</a>).<elsevierMultimedia ident="fig0015"></elsevierMultimedia>To further evaluate LV function and anatomy and the shape of the aneurysms and to differentiate between true and pseudoaneurysms, magnetic resonance imaging (MRI) (Achieva 1.5 T system, Philips Healthcare, Andover, USA) was performed. Using a dedicated cardiac coil, images were acquired with electrocardiographic gating and balanced turbo field echo/fast field echo in short-axis, vertical long-axis, 4-chamber and transverse planes, followed by perfusion studies and delayed contrast-enhanced imaging. These showed LV ejection fraction of 39.5% and stroke volume of 55.4 ml. Images were analyzed for the location of aneurysms, maximal internal width of the orifice, and maximal parallel internal diameter. The largest outpouching on the anterolateral wall of the LV showed thinning of the overlying myocardium (thickness 3.5 mm). The neck and maximum diameter were both 24 mm and the ratio of maximal internal width of the orifice and maximal parallel internal diameter was 1.0. There was no delayed pericardial enhancement. All these findings suggested that this was a true aneurysm. Other aneurysms on the anterior wall and submitral area were smaller and had similar characteristics (<a class="elsevierStyleCrossRef" href="#fig0020">Figure 4</a>). MRI ruled out inflammatory and infiltrative disorders.<elsevierMultimedia ident="fig0020"></elsevierMultimedia>The patient denied a history of rheumatic or systemic diseases, toxin exposure or chest trauma. There was no involvement of skin, mucosa or other organ systems. Family history was insignificant for CHF, cardiomyopathy, arrhythmias or sudden cardiac death. Serum levels of inflammatory markers (erythrocyte sedimentation rate and C-reactive protein), cardiac biomarkers and serum protein electrophoresis were normal. Investigations for Chagas disease, syphilis, sarcoidosis, tuberculosis, connective tissue diseases, and human immunodeficiency virus (HIV) were negative. Holter monitoring performed to screen for ventricular extrasystoles and tachyarrhythmias was normal. Abdominal ultrasound showed normal liver and kidneys.Considering the idiopathic nature of the aneurysms and the absence of overt decompensated CHF, angina, arrhythmias and embolism, the patient was considered for medical management in the form of beta-blockers to prevent arrhythmias and warfarin to prevent systemic embolism. At 18 months of follow-up she was free of CHF, arrhythmias and embolism.DiscussionLVAs are usually classified as congenital or acquired, i.e. arising from a cardiac or non-cardiac disorder.<a class="elsevierStyleCrossRef" href="#bib0200">3</a> Acquired LVAs most frequently result from MI<a class="elsevierStyleCrossRefs" href="#bib0200">3,5</a> or coronary artery malformations such as fistulas.<a class="elsevierStyleCrossRef" href="#bib0215">6</a> They may also be present in arrhythmogenic right ventricular cardiomyopathy,<a class="elsevierStyleCrossRef" href="#bib0220">7</a> hypertrophic cardiomyopathy,<a class="elsevierStyleCrossRef" href="#bib0225">8</a> and myocarditis.<a class="elsevierStyleCrossRef" href="#bib0230">9</a> Underlying non-cardiac systemic diseases include sarcoidosis,<a class="elsevierStyleCrossRef" href="#bib0235">10</a> Chagas disease,<a class="elsevierStyleCrossRef" href="#bib0240">11</a> lupus erythematosus,<a class="elsevierStyleCrossRef" href="#bib0245">12</a> Behcet's disease,<a class="elsevierStyleCrossRef" href="#bib0250">13</a> tuberculosis,<a class="elsevierStyleCrossRef" href="#bib0205">4</a> syphilis<a class="elsevierStyleCrossRef" href="#bib0255">14</a> or HIV.<a class="elsevierStyleCrossRef" href="#bib0260">15</a> As a rare complication, LVAs have also been observed in glycogen storage diseases,<a class="elsevierStyleCrossRef" href="#bib0265">16</a> hyperimmunoglobulin-E syndrome<a class="elsevierStyleCrossRef" href="#bib0270">17</a> and blunt chest trauma.<a class="elsevierStyleCrossRef" href="#bib0275">18</a> Congenital LVAs (occurring in the perinatal period) have been detected as early as the second trimester of gestation<a class="elsevierStyleCrossRef" href="#bib0280">19</a> and have been associated with severe comorbidities and intrauterine death. Idiopathic LVAs (without an identifiable underlying cause) are rare.<a class="elsevierStyleCrossRefs" href="#bib0200">3,20</a> Weakness of the LV wall, with herniation of the endocardium under the influence of ventricular pressure, and resulting in the formation of a fibrous walled aneurysm with calcium and thrombus deposits in its walls, sometimes with adhesions to the adjacent pericardium, has been suggested as the underlying pathogenesis.<a class="elsevierStyleCrossRef" href="#bib0290">21</a> Idiopathic submitral LVA, of non-ischemic origin, a rare entity, is commonly described in young black Africans and sometimes in Caucasians.<a class="elsevierStyleCrossRef" href="#bib0295">22</a> The higher prevalence in certain ethnic groups and the absence of a clear etiology suggest a congenital etiology.<a class="elsevierStyleCrossRef" href="#bib0295">22</a> Idiopathic LVA appears to be caused by an abnormality in the junction between the cardiac muscle and the fibrous structure of the heart. It can vary in size from millimeters to several centimeters.<a class="elsevierStyleCrossRef" href="#bib0295">22</a> These are anatomically distinct from congenital diverticula, which are defined as having only a narrow communication with the ventricle.<a class="elsevierStyleCrossRef" href="#bib0260">15</a> Multiple idiopathic LVAs are distinctly unusual and are rarely reported.As with aneurysms of atherosclerotic origin, these entities may be associated with a variety of symptoms, including chest discomfort,<a class="elsevierStyleCrossRef" href="#bib0285">20</a> ventricular tachyarrhythmias leading to sudden cardiac death,<a class="elsevierStyleCrossRef" href="#bib0200">3</a> angina,<a class="elsevierStyleCrossRef" href="#bib0300">23</a> CHF,<a class="elsevierStyleCrossRef" href="#bib0205">4</a> or recurrent thromboembolism.<a class="elsevierStyleCrossRef" href="#bib0285">20</a> The tissue of the LVA has been described as inhomogeneous, with viable, normal myocytes, fibrotic tissue, and/or hypertrophic myocytes.<a class="elsevierStyleCrossRefs" href="#bib0200">3,4,24</a> This may well represent an arrhythmogenic substrate due to local conduction delay and dispersion of excitability and refractoriness, which may be augmented by catecholamines during exercise or mental stress.<a class="elsevierStyleCrossRef" href="#bib0310">25</a> A study has demonstrated that inflammatory LV microaneurysms, often of viral origin, can be a cause of idiopathic ventricular tachyarrhythmias.<a class="elsevierStyleCrossRef" href="#bib0315">26</a> In addition, large aneurysms interfere with LV performance through loss of contractile tissue due to mixture of scar tissue and viable myocardium and also by a paradoxical expansion,<a class="elsevierStyleCrossRef" href="#bib0190">1</a> leading to CHF.LVAs have been depicted and characterized by various imaging modalities.<a class="elsevierStyleCrossRef" href="#bib0200">3</a> Radionuclide ventriculography and echocardiography can demonstrate LVAs more readily.<a class="elsevierStyleCrossRef" href="#bib0190">1</a> A definitive diagnosis of LVA is best made non-invasively by echocardiography, which also helps in distinguishing a true from a pseudoaneurysm based on the demonstration of a narrow neck in relation to cavity size in the latter.<a class="elsevierStyleCrossRef" href="#bib0320">27</a> The myocardium surrounding a true aneurysm is in continuity with the rest of the myocardium, as in our case, while there is no myocardium around a pseudoaneurysm, leading to a breach in the continuity of the normal myocardium.<a class="elsevierStyleCrossRef" href="#bib0325">28</a> An abrupt discontinuity of the endocardial image between the aneurysm and adjacent normal myocardium is a characteristic finding with a pseudoaneurysm.<a class="elsevierStyleCrossRef" href="#bib0255">14</a> True and pseudoaneurysms can both be non-contractile or dyskinetic and may contain thrombus.<a class="elsevierStyleCrossRefs" href="#bib0325">28,29</a> Color flow Doppler is useful in establishing the diagnosis as flow in and out of the aneurysm, as well as abnormal flow within it, can be detected. Pulsed Doppler imaging can reveal a to-and-fro pattern with characteristic respiratory variation in peak systolic velocity.<a class="elsevierStyleCrossRef" href="#bib0190">1</a> However, echocardiography has the limitation of occasional failure to define the neck.<a class="elsevierStyleCrossRef" href="#bib0335">30</a>Left ventriculography is another potential tool that can detect an abnormal bulge or dyskinetic wall motion in the LV contour during systole; however, it is an invasive method. True aneurysms have a wider neck, as in our case, in contrast to the narrow neck of a pseudoaneurysm.<a class="elsevierStyleCrossRefs" href="#bib0340">31,32</a> Contrast remains within the cavity of the pseudoaneurysm for several beats after injection.<a class="elsevierStyleCrossRefs" href="#bib0340">31,32</a> Coronary arteries can extend on the aneurysmal wall in a true aneurysm, while, in a pseudoaneurysm with disrupted myocardium, a cavity is created by blood and pericardium and the coronaries do not drape over this paraventricular chamber.<a class="elsevierStyleCrossRef" href="#bib0345">32</a> A true aneurysm is less likely than a pseudoaneurysm to be secondary to MI, leading to abnormal patency of at least one of the coronary arteries. Other clues include a characteristic bulge and calcified LV silhouette on the chest radiograph, which is a specific finding but not sensitive.<a class="elsevierStyleCrossRef" href="#bib0190">1</a> The presence of a discrete bulge anteriorly is more in favor of a true aneurysm.<a class="elsevierStyleCrossRef" href="#bib0335">30</a> In the case of a pseudoaneurysm, the chest X-ray may show a pericardial mass with a characteristic notch at the border of the mass.<a class="elsevierStyleCrossRef" href="#bib0255">14</a> In our case, by contrast, the borders were relatively smooth and a bulge was present anteriorly.Recently, MRI has emerged as the preferred non-invasive technique for assessment of LV shape, the degree of aneurysm thinning, and resectability.<a class="elsevierStyleCrossRefs" href="#bib0350">33,34</a> MRI can distinguish between pericardium, thrombus, and myocardium, which are not easily distinguished by contrast ventriculography,<a class="elsevierStyleCrossRef" href="#bib0335">30</a> and helps resolve uncertainty between a true and a pseudoaneurysm. Contrast-enhanced MRI provides additional information on myocardial tissue characteristics, perfusion, and viability.<a class="elsevierStyleCrossRef" href="#bib0200">3</a> In the case of a true aneurysm, the tissue making up the wall of the aneurysm shows delayed myocardial enhancement. As the wall of a pseudoaneurysm is composed only of pericardium, it shows no delayed myocardial enhancement; however, its border does show enhancement.<a class="elsevierStyleCrossRef" href="#bib0335">30</a> Pseudoaneurysms may show delayed pericardial enhancement.<a class="elsevierStyleCrossRef" href="#bib0330">29</a> The ratio of maximal internal width of the orifice and maximal parallel internal diameter of 1.0 and the absence of delayed pericardial enhancement confirmed the aneurysms as true ones in the case presented.<a class="elsevierStyleCrossRef" href="#bib0330">29</a> To elucidate the pathogenesis further, radionuclide imaging techniques can be used to assess myocardial viability (2-[fluorine-18]fluoro-2-deoxy-D-glucose positron emission tomography) and regional sympathetic innervation ([iodine-123]metaiodobenzylguanidine single photon emission computed tomography).<a class="elsevierStyleCrossRef" href="#bib0200">3</a> Endomyocardial biopsy can demonstrate myocarditis, sarcoidosis, arrhythmogenic right ventricular cardiomyopathy, or storage disease.<a class="elsevierStyleCrossRef" href="#bib0200">3</a> Programmed ventricular stimulation can help to induce clinically silent arrhythmias.<a class="elsevierStyleCrossRef" href="#bib0200">3</a> As there was no history suggestive of hemodynamically significant arrhythmias, we assessed our patient with Holter monitoring only.Treatment and prognosis of idiopathic LVAs are dependent on their size, location, and degree of valvular involvement, CHF functional class, and presence of ventricular tachyarrhythmias.<a class="elsevierStyleCrossRef" href="#bib0200">3</a> Management strategies therefore range from antiarrhythmic drugs<a class="elsevierStyleCrossRef" href="#bib0360">35</a> to ablation for ventricular tachycardia,<a class="elsevierStyleCrossRef" href="#bib0365">36</a> implantation of a cardioverter-defibrillator,<a class="elsevierStyleCrossRef" href="#bib0305">24</a> treatment of CHF<a class="elsevierStyleCrossRef" href="#bib0200">3</a> or (less frequently) surgical aneurysmectomy.<a class="elsevierStyleCrossRef" href="#bib0370">37</a> The latter is carried out to improve clinical manifestations, mostly CHF but sometimes also angina, embolization, and life-threatening tachyarrhythmias.<a class="elsevierStyleCrossRef" href="#bib0190">1</a> However, prospective long-term follow-up studies comparing the different strategies are not available.<a class="elsevierStyleCrossRef" href="#bib0200">3</a> Our patient was successfully managed with beta-blockers to prevent arrhythmias and oral anticoagulants to prevent thromboembolism. Idiopathic multiple LVAs in a young female demonstrated on ventriculography were reported to be treated conservatively with medical therapy with acceptable clinical course and without adverse clinical sequelae.<a class="elsevierStyleCrossRef" href="#bib0285">20</a>ConclusionMultiple LVAs in a patient can be idiopathic in nature and have varied presentations. They can be managed conservatively in the absence of angina, decompensated CHF and tachyarrhythmias.Ethical disclosuresProtection of human and animal subjectsThe authors declare that no experiments were performed on humans or animals for this study.Confidentiality of dataThe authors declare that no patient data appear in this article.Right to privacy and informed consentThe authors have obtained the written informed consent of the patients or subjects mentioned in the article. The corresponding author is in possession of this document.Conflicts of interestThe authors have no conflicts of interest to declare." "textoCompletoSecciones" => array:1 [ "secciones" => array:11 [ 0 => array:3 [ "identificador" => "xres818316" "titulo" => "Abstract" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0005" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec815349" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres818317" "titulo" => "Resumo" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0010" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec815348" "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" => "Conclusion" ] 8 => array:3 [ "identificador" => "sec0025" "titulo" => "Ethical disclosures" "secciones" => array:3 [ 0 => array:2 [ "identificador" => "sec0030" "titulo" => "Protection of human and animal subjects" ] 1 => array:2 [ "identificador" => "sec0035" "titulo" => "Confidentiality of data" ] 2 => array:2 [ "identificador" => "sec0040" "titulo" => "Right to privacy and informed consent" ] ] ] 9 => array:2 [ "identificador" => "sec0045" "titulo" => "Conflicts of interest" ] 10 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2014-11-18" "fechaAceptado" => "2015-09-02" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec815349" "palabras" => array:6 [ 0 => "Chest radiograph" 1 => "Coronary angiogram" 2 => "Cardiac catheterization" 3 => "Ventriculogram" 4 => "Cardiac magnetic resonance imaging" 5 => "Aneurysm" ] ] ] "pt" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palavras-chave" "identificador" => "xpalclavsec815348" "palabras" => array:6 [ 0 => "Radiografia de tórax" 1 => "Angiografia coronária" 2 => "Cateterismo cardíaco" 3 => "Ecografia ventricular" 4 => "Ressonância magnética cardíaca" 5 => "Aneurisma" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:2 [ "titulo" => "Abstract" "resumen" => "Multiple left ventricular aneurysms (LVAs) are rare, especially in a young female. A 29-year-old woman presented vague symptoms. Multiple LVAs were revealed and confirmed on different imaging modalities, including chest radiography, echocardiography, contrast ventriculography and cardiac magnetic resonance imaging. Detailed work-up for probable etiologies including ischemic, infectious, inflammatory and autoimmune causes was negative. In the absence of angina, decompensated congestive heart failure, arrhythmias and embolism, the patient was managed conservatively, with excellent mid-term outcome." ] "pt" => array:2 [ "titulo" => "Resumo" "resumen" => "Múltiplos aneurismas no ventrículo esquerdo (MAVE) são uma situação rara em especial numa jovem que apresentou queixas vagas. Vários MAVE foram revelados e confirmados em diferentes modalidades de imagem. A doente submeteu-se a radiografia de tórax, ecocardiografia, ecografia de contraste e ressonância magnética cardíaca. A investigação minuciosa de etiologias isquémica, infecciosa, inflamatória e autoimune foi negativa. Dada a ausência de angina, insuficiência cardíaca congestiva, arritmias e embolia, a doente foi tratada de forma conservadora apresentando um excelente prognóstico a médio prazo." ] ] "multimedia" => array:4 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1459 "Ancho" => 3344 "Tamanyo" => 895803 ] ] "descripcion" => array:1 [ "en" => "(A) Chest radiograph in posteroanterior view showing large calcified left ventricular apical aneurysm (*) and basal aneurysm (**); (B) electrocardiogram showing no pathological Q waves and normal progression of precordial R wave." ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 3264 "Ancho" => 2374 "Tamanyo" => 675419 ] ] "descripcion" => array:1 [ "en" => "Transthoracic two-dimensional echocardiogram with color Doppler. (A) Apical 4-chamber view in systole showing apical aneurysm (*); (B) parasternal long-axis view in diastole showing submitral aneurysm (**)." ] ] 2 => array:7 [ "identificador" => "fig0015" "etiqueta" => "Figure 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 1389 "Ancho" => 2672 "Tamanyo" => 268263 ] ] "descripcion" => array:1 [ "en" => "Left ventriculogram. (A) Right anterior oblique view in diastole showing apical aneurysm (*), basal anterior aneurysm (**), submitral aneurysm (***) and normal left coronary artery branches (arrow); (B) lateral view in diastole showing LV apical aneurysm (*), basal anterior aneurysm (**) and normal left coronary artery branches (arrow)." ] ] 3 => array:7 [ "identificador" => "fig0020" "etiqueta" => "Figure 4" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr4.jpeg" "Alto" => 1215 "Ancho" => 2672 "Tamanyo" => 238244 ] ] "descripcion" => array:1 [ "en" => "Cardiac magnetic resonance imaging. 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Case report

Multiple left ventricular aneurysms in a young female

Múltiplos aneurismas do ventrículo esquerdo numa jovem

Abhishek P. Raval

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docabs4u@gmail.com

Corresponding author.

, Anand Shukla, Rajiv Garg, Yashpal Rana, Komal Shah

U.N. Mehta Institute of Cardiology and Research Centre (UNMICRC), Ahmedabad, India

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          "en" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Transthoracic two-dimensional echocardiogram with color Doppler&#46; &#40;A&#41; Apical 4-chamber view in systole showing apical aneurysm &#40;&#42;&#41;&#59; &#40;B&#41; parasternal long-axis view in diastole showing submitral aneurysm &#40;&#42;&#42;&#41;&#46;</p>"
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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Left ventricular aneurysm &#40;LVA&#41; is usually defined as a segment of the ventricular wall that exhibits paradoxical systolic expansion&#59; the term is generally reserved for a discrete&#44; dyskinetic area of the left ventricular &#40;LV&#41; wall with a broad neck&#46;<a class="elsevierStyleCrossRefs" href="#bib0190"><span class="elsevierStyleSup">1&#44;2</span></a> It most frequently develops after myocardial infarction &#40;MI&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0200"><span class="elsevierStyleSup">3</span></a> However&#44; other causes may be infectious&#44; inflammatory&#44; metabolic or autoimmune in nature&#46; Multiple idiopathic LVAs are distinctly unusual and rarely reported&#46; The clinical spectrum ranges from asymptomatic to congestive heart failure &#40;CHF&#41; to life-threatening ventricular arrhythmias and cardiac arrest&#46;<a class="elsevierStyleCrossRefs" href="#bib0200"><span class="elsevierStyleSup">3&#44;4</span></a> Herein&#44; we report the case of a young female with multiple large LVAs&#44; managed conservatively in the absence of overt CHF&#44; arrhythmias and embolism&#44; with excellent outcome&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Case report</span><p id="par0010" class="elsevierStylePara elsevierViewall">A 29-year-old woman presented with easy fatigability and chest discomfort for several months&#46; These symptoms were insidious in onset and progressed little&#46; There was no history of palpitations&#44; syncope or dyspnea&#46; She was hemodynamically stable with diffuse apex beat shifted downward and outward&#46; The chest radiograph showed calcified LV apical and basal aneurysms&#46; The electrocardiogram showed no pathological Q waves and normal precordial R-wave progression &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Figure 1</a>&#41;&#46; Two-dimensional transthoracic echocardiography &#40;iE33 xMATRIX&#44; Philips Healthcare&#44; Andover&#44; MA&#44; USA&#41; showed moderate LV dysfunction&#59; multiple LVAs &#40;large apical aneurysm&#44; moderate sized submitral aneurysm&#44; and basal anterior aneurysm&#41;&#59; normal contractility of the rest of the LV wall&#59; and normal valves&#44; other chambers and great vessels &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Figure 2</a>&#41;&#46; The echocardiogram showed continuity of the myocardium of the aneurysms with the rest of the myocardium&#46; Color flow Doppler showed flow in and out of the aneurysms&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0015" class="elsevierStylePara elsevierViewall">The coronary angiogram &#40;Philips Medical Systems&#44; Nederland B&#46;V&#46;&#41; showed normal epicardial coronaries&#46; Catheterization showed LV pressure of 114&#47;3 mmHg&#46; Systemic and pulmonary arterial&#44; right atrial and ventricular pressures were also normal&#46; The left ventriculogram showed a large LV apical aneurysm with a heavily calcified thrombosed distal part&#44; a large aneurysm of the basal anterior wall with a smooth and calcified distal part&#44; and a moderate sized submitral aneurysm&#46; All the aneurysms had large necks&#44; poor contractility and paradoxical systolic filling&#46; Contrast clearance was slightly delayed by a beat &#40;<a class="elsevierStyleCrossRef" href="#fig0015">Figure 3</a>&#41;&#46;</p><elsevierMultimedia ident="fig0015"></elsevierMultimedia><p id="par0020" class="elsevierStylePara elsevierViewall">To further evaluate LV function and anatomy and the shape of the aneurysms and to differentiate between true and pseudoaneurysms&#44; magnetic resonance imaging &#40;MRI&#41; &#40;Achieva 1&#46;5 T system&#44; Philips Healthcare&#44; Andover&#44; USA&#41; was performed&#46; Using a dedicated cardiac coil&#44; images were acquired with electrocardiographic gating and balanced turbo field echo&#47;fast field echo in short-axis&#44; vertical long-axis&#44; 4-chamber and transverse planes&#44; followed by perfusion studies and delayed contrast-enhanced imaging&#46; These showed LV ejection fraction of 39&#46;5&#37; and stroke volume of 55&#46;4 ml&#46; Images were analyzed for the location of aneurysms&#44; maximal internal width of the orifice&#44; and maximal parallel internal diameter&#46; The largest outpouching on the anterolateral wall of the LV showed thinning of the overlying myocardium &#40;thickness 3&#46;5 mm&#41;&#46; The neck and maximum diameter were both 24 mm and the ratio of maximal internal width of the orifice and maximal parallel internal diameter was 1&#46;0&#46; There was no delayed pericardial enhancement&#46; All these findings suggested that this was a true aneurysm&#46; Other aneurysms on the anterior wall and submitral area were smaller and had similar characteristics &#40;<a class="elsevierStyleCrossRef" href="#fig0020">Figure 4</a>&#41;&#46; MRI ruled out inflammatory and infiltrative disorders&#46;</p><elsevierMultimedia ident="fig0020"></elsevierMultimedia><p id="par0025" class="elsevierStylePara elsevierViewall">The patient denied a history of rheumatic or systemic diseases&#44; toxin exposure or chest trauma&#46; There was no involvement of skin&#44; mucosa or other organ systems&#46; Family history was insignificant for CHF&#44; cardiomyopathy&#44; arrhythmias or sudden cardiac death&#46; Serum levels of inflammatory markers &#40;erythrocyte sedimentation rate and C-reactive protein&#41;&#44; cardiac biomarkers and serum protein electrophoresis were normal&#46; Investigations for Chagas disease&#44; syphilis&#44; sarcoidosis&#44; tuberculosis&#44; connective tissue diseases&#44; and human immunodeficiency virus &#40;HIV&#41; were negative&#46; Holter monitoring performed to screen for ventricular extrasystoles and tachyarrhythmias was normal&#46; Abdominal ultrasound showed normal liver and kidneys&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">Considering the idiopathic nature of the aneurysms and the absence of overt decompensated CHF&#44; angina&#44; arrhythmias and embolism&#44; the patient was considered for medical management in the form of beta-blockers to prevent arrhythmias and warfarin to prevent systemic embolism&#46; At 18 months of follow-up she was free of CHF&#44; arrhythmias and embolism&#46;</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Discussion</span><p id="par0035" class="elsevierStylePara elsevierViewall">LVAs are usually classified as congenital or acquired&#44; i&#46;e&#46; arising from a cardiac or non-cardiac disorder&#46;<a class="elsevierStyleCrossRef" href="#bib0200"><span class="elsevierStyleSup">3</span></a> Acquired LVAs most frequently result from MI<a class="elsevierStyleCrossRefs" href="#bib0200"><span class="elsevierStyleSup">3&#44;5</span></a> or coronary artery malformations such as fistulas&#46;<a class="elsevierStyleCrossRef" href="#bib0215"><span class="elsevierStyleSup">6</span></a> They may also be present in arrhythmogenic right ventricular cardiomyopathy&#44;<a class="elsevierStyleCrossRef" href="#bib0220"><span class="elsevierStyleSup">7</span></a> hypertrophic cardiomyopathy&#44;<a class="elsevierStyleCrossRef" href="#bib0225"><span class="elsevierStyleSup">8</span></a> and myocarditis&#46;<a class="elsevierStyleCrossRef" href="#bib0230"><span class="elsevierStyleSup">9</span></a> Underlying non-cardiac systemic diseases include sarcoidosis&#44;<a class="elsevierStyleCrossRef" href="#bib0235"><span class="elsevierStyleSup">10</span></a> Chagas disease&#44;<a class="elsevierStyleCrossRef" href="#bib0240"><span class="elsevierStyleSup">11</span></a> lupus erythematosus&#44;<a class="elsevierStyleCrossRef" href="#bib0245"><span class="elsevierStyleSup">12</span></a> Behcet&#39;s disease&#44;<a class="elsevierStyleCrossRef" href="#bib0250"><span class="elsevierStyleSup">13</span></a> tuberculosis&#44;<a class="elsevierStyleCrossRef" href="#bib0205"><span class="elsevierStyleSup">4</span></a> syphilis<a class="elsevierStyleCrossRef" href="#bib0255"><span class="elsevierStyleSup">14</span></a> or HIV&#46;<a class="elsevierStyleCrossRef" href="#bib0260"><span class="elsevierStyleSup">15</span></a> As a rare complication&#44; LVAs have also been observed in glycogen storage diseases&#44;<a class="elsevierStyleCrossRef" href="#bib0265"><span class="elsevierStyleSup">16</span></a> hyperimmunoglobulin-E syndrome<a class="elsevierStyleCrossRef" href="#bib0270"><span class="elsevierStyleSup">17</span></a> and blunt chest trauma&#46;<a class="elsevierStyleCrossRef" href="#bib0275"><span class="elsevierStyleSup">18</span></a> Congenital LVAs &#40;occurring in the perinatal period&#41; have been detected as early as the second trimester of gestation<a class="elsevierStyleCrossRef" href="#bib0280"><span class="elsevierStyleSup">19</span></a> and have been associated with severe comorbidities and intrauterine death&#46; Idiopathic LVAs &#40;without an identifiable underlying cause&#41; are rare&#46;<a class="elsevierStyleCrossRefs" href="#bib0200"><span class="elsevierStyleSup">3&#44;20</span></a> Weakness of the LV wall&#44; with herniation of the endocardium under the influence of ventricular pressure&#44; and resulting in the formation of a fibrous walled aneurysm with calcium and thrombus deposits in its walls&#44; sometimes with adhesions to the adjacent pericardium&#44; has been suggested as the underlying pathogenesis&#46;<a class="elsevierStyleCrossRef" href="#bib0290"><span class="elsevierStyleSup">21</span></a> Idiopathic submitral LVA&#44; of non-ischemic origin&#44; a rare entity&#44; is commonly described in young black Africans and sometimes in Caucasians&#46;<a class="elsevierStyleCrossRef" href="#bib0295"><span class="elsevierStyleSup">22</span></a> The higher prevalence in certain ethnic groups and the absence of a clear etiology suggest a congenital etiology&#46;<a class="elsevierStyleCrossRef" href="#bib0295"><span class="elsevierStyleSup">22</span></a> Idiopathic LVA appears to be caused by an abnormality in the junction between the cardiac muscle and the fibrous structure of the heart&#46; It can vary in size from millimeters to several centimeters&#46;<a class="elsevierStyleCrossRef" href="#bib0295"><span class="elsevierStyleSup">22</span></a> These are anatomically distinct from congenital diverticula&#44; which are defined as having only a narrow communication with the ventricle&#46;<a class="elsevierStyleCrossRef" href="#bib0260"><span class="elsevierStyleSup">15</span></a> Multiple idiopathic LVAs are distinctly unusual and are rarely reported&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">As with aneurysms of atherosclerotic origin&#44; these entities may be associated with a variety of symptoms&#44; including chest discomfort&#44;<a class="elsevierStyleCrossRef" href="#bib0285"><span class="elsevierStyleSup">20</span></a> ventricular tachyarrhythmias leading to sudden cardiac death&#44;<a class="elsevierStyleCrossRef" href="#bib0200"><span class="elsevierStyleSup">3</span></a> angina&#44;<a class="elsevierStyleCrossRef" href="#bib0300"><span class="elsevierStyleSup">23</span></a> CHF&#44;<a class="elsevierStyleCrossRef" href="#bib0205"><span class="elsevierStyleSup">4</span></a> or recurrent thromboembolism&#46;<a class="elsevierStyleCrossRef" href="#bib0285"><span class="elsevierStyleSup">20</span></a> The tissue of the LVA has been described as inhomogeneous&#44; with viable&#44; normal myocytes&#44; fibrotic tissue&#44; and&#47;or hypertrophic myocytes&#46;<a class="elsevierStyleCrossRefs" href="#bib0200"><span class="elsevierStyleSup">3&#44;4&#44;24</span></a> This may well represent an arrhythmogenic substrate due to local conduction delay and dispersion of excitability and refractoriness&#44; which may be augmented by catecholamines during exercise or mental stress&#46;<a class="elsevierStyleCrossRef" href="#bib0310"><span class="elsevierStyleSup">25</span></a> A study has demonstrated that inflammatory LV microaneurysms&#44; often of viral origin&#44; can be a cause of idiopathic ventricular tachyarrhythmias&#46;<a class="elsevierStyleCrossRef" href="#bib0315"><span class="elsevierStyleSup">26</span></a> In addition&#44; large aneurysms interfere with LV performance through loss of contractile tissue due to mixture of scar tissue and viable myocardium and also by a paradoxical expansion&#44;<a class="elsevierStyleCrossRef" href="#bib0190"><span class="elsevierStyleSup">1</span></a> leading to CHF&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">LVAs have been depicted and characterized by various imaging modalities&#46;<a class="elsevierStyleCrossRef" href="#bib0200"><span class="elsevierStyleSup">3</span></a> Radionuclide ventriculography and echocardiography can demonstrate LVAs more readily&#46;<a class="elsevierStyleCrossRef" href="#bib0190"><span class="elsevierStyleSup">1</span></a> A definitive diagnosis of LVA is best made non-invasively by echocardiography&#44; which also helps in distinguishing a true from a pseudoaneurysm based on the demonstration of a narrow neck in relation to cavity size in the latter&#46;<a class="elsevierStyleCrossRef" href="#bib0320"><span class="elsevierStyleSup">27</span></a> The myocardium surrounding a true aneurysm is in continuity with the rest of the myocardium&#44; as in our case&#44; while there is no myocardium around a pseudoaneurysm&#44; leading to a breach in the continuity of the normal myocardium&#46;<a class="elsevierStyleCrossRef" href="#bib0325"><span class="elsevierStyleSup">28</span></a> An abrupt discontinuity of the endocardial image between the aneurysm and adjacent normal myocardium is a characteristic finding with a pseudoaneurysm&#46;<a class="elsevierStyleCrossRef" href="#bib0255"><span class="elsevierStyleSup">14</span></a> True and pseudoaneurysms can both be non-contractile or dyskinetic and may contain thrombus&#46;<a class="elsevierStyleCrossRefs" href="#bib0325"><span class="elsevierStyleSup">28&#44;29</span></a> Color flow Doppler is useful in establishing the diagnosis as flow in and out of the aneurysm&#44; as well as abnormal flow within it&#44; can be detected&#46; Pulsed Doppler imaging can reveal a to-and-fro pattern with characteristic respiratory variation in peak systolic velocity&#46;<a class="elsevierStyleCrossRef" href="#bib0190"><span class="elsevierStyleSup">1</span></a> However&#44; echocardiography has the limitation of occasional failure to define the neck&#46;<a class="elsevierStyleCrossRef" href="#bib0335"><span class="elsevierStyleSup">30</span></a></p><p id="par0050" class="elsevierStylePara elsevierViewall">Left ventriculography is another potential tool that can detect an abnormal bulge or dyskinetic wall motion in the LV contour during systole&#59; however&#44; it is an invasive method&#46; True aneurysms have a wider neck&#44; as in our case&#44; in contrast to the narrow neck of a pseudoaneurysm&#46;<a class="elsevierStyleCrossRefs" href="#bib0340"><span class="elsevierStyleSup">31&#44;32</span></a> Contrast remains within the cavity of the pseudoaneurysm for several beats after injection&#46;<a class="elsevierStyleCrossRefs" href="#bib0340"><span class="elsevierStyleSup">31&#44;32</span></a> Coronary arteries can extend on the aneurysmal wall in a true aneurysm&#44; while&#44; in a pseudoaneurysm with disrupted myocardium&#44; a cavity is created by blood and pericardium and the coronaries do not drape over this paraventricular chamber&#46;<a class="elsevierStyleCrossRef" href="#bib0345"><span class="elsevierStyleSup">32</span></a> A true aneurysm is less likely than a pseudoaneurysm to be secondary to MI&#44; leading to abnormal patency of at least one of the coronary arteries&#46; Other clues include a characteristic bulge and calcified LV silhouette on the chest radiograph&#44; which is a specific finding but not sensitive&#46;<a class="elsevierStyleCrossRef" href="#bib0190"><span class="elsevierStyleSup">1</span></a> The presence of a discrete bulge anteriorly is more in favor of a true aneurysm&#46;<a class="elsevierStyleCrossRef" href="#bib0335"><span class="elsevierStyleSup">30</span></a> In the case of a pseudoaneurysm&#44; the chest X-ray may show a pericardial mass with a characteristic notch at the border of the mass&#46;<a class="elsevierStyleCrossRef" href="#bib0255"><span class="elsevierStyleSup">14</span></a> In our case&#44; by contrast&#44; the borders were relatively smooth and a bulge was present anteriorly&#46;</p><p id="par0055" class="elsevierStylePara elsevierViewall">Recently&#44; MRI has emerged as the preferred non-invasive technique for assessment of LV shape&#44; the degree of aneurysm thinning&#44; and resectability&#46;<a class="elsevierStyleCrossRefs" href="#bib0350"><span class="elsevierStyleSup">33&#44;34</span></a> MRI can distinguish between pericardium&#44; thrombus&#44; and myocardium&#44; which are not easily distinguished by contrast ventriculography&#44;<a class="elsevierStyleCrossRef" href="#bib0335"><span class="elsevierStyleSup">30</span></a> and helps resolve uncertainty between a true and a pseudoaneurysm&#46; Contrast-enhanced MRI provides additional information on myocardial tissue characteristics&#44; perfusion&#44; and viability&#46;<a class="elsevierStyleCrossRef" href="#bib0200"><span class="elsevierStyleSup">3</span></a> In the case of a true aneurysm&#44; the tissue making up the wall of the aneurysm shows delayed myocardial enhancement&#46; As the wall of a pseudoaneurysm is composed only of pericardium&#44; it shows no delayed myocardial enhancement&#59; however&#44; its border does show enhancement&#46;<a class="elsevierStyleCrossRef" href="#bib0335"><span class="elsevierStyleSup">30</span></a> Pseudoaneurysms may show delayed pericardial enhancement&#46;<a class="elsevierStyleCrossRef" href="#bib0330"><span class="elsevierStyleSup">29</span></a> The ratio of maximal internal width of the orifice and maximal parallel internal diameter of 1&#46;0 and the absence of delayed pericardial enhancement confirmed the aneurysms as true ones in the case presented&#46;<a class="elsevierStyleCrossRef" href="#bib0330"><span class="elsevierStyleSup">29</span></a> To elucidate the pathogenesis further&#44; radionuclide imaging techniques can be used to assess myocardial viability &#40;2-&#91;fluorine-18&#93;fluoro-2-deoxy-D-glucose positron emission tomography&#41; and regional sympathetic innervation &#40;&#91;iodine-123&#93;metaiodobenzylguanidine single photon emission computed tomography&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0200"><span class="elsevierStyleSup">3</span></a> Endomyocardial biopsy can demonstrate myocarditis&#44; sarcoidosis&#44; arrhythmogenic right ventricular cardiomyopathy&#44; or storage disease&#46;<a class="elsevierStyleCrossRef" href="#bib0200"><span class="elsevierStyleSup">3</span></a> Programmed ventricular stimulation can help to induce clinically silent arrhythmias&#46;<a class="elsevierStyleCrossRef" href="#bib0200"><span class="elsevierStyleSup">3</span></a> As there was no history suggestive of hemodynamically significant arrhythmias&#44; we assessed our patient with Holter monitoring only&#46;</p><p id="par0060" class="elsevierStylePara elsevierViewall">Treatment and prognosis of idiopathic LVAs are dependent on their size&#44; location&#44; and degree of valvular involvement&#44; CHF functional class&#44; and presence of ventricular tachyarrhythmias&#46;<a class="elsevierStyleCrossRef" href="#bib0200"><span class="elsevierStyleSup">3</span></a> Management strategies therefore range from antiarrhythmic drugs<a class="elsevierStyleCrossRef" href="#bib0360"><span class="elsevierStyleSup">35</span></a> to ablation for ventricular tachycardia&#44;<a class="elsevierStyleCrossRef" href="#bib0365"><span class="elsevierStyleSup">36</span></a> implantation of a cardioverter-defibrillator&#44;<a class="elsevierStyleCrossRef" href="#bib0305"><span class="elsevierStyleSup">24</span></a> treatment of CHF<a class="elsevierStyleCrossRef" href="#bib0200"><span class="elsevierStyleSup">3</span></a> or &#40;less frequently&#41; surgical aneurysmectomy&#46;<a class="elsevierStyleCrossRef" href="#bib0370"><span class="elsevierStyleSup">37</span></a> The latter is carried out to improve clinical manifestations&#44; mostly CHF but sometimes also angina&#44; embolization&#44; and life-threatening tachyarrhythmias&#46;<a class="elsevierStyleCrossRef" href="#bib0190"><span class="elsevierStyleSup">1</span></a> However&#44; prospective long-term follow-up studies comparing the different strategies are not available&#46;<a class="elsevierStyleCrossRef" href="#bib0200"><span class="elsevierStyleSup">3</span></a> Our patient was successfully managed with beta-blockers to prevent arrhythmias and oral anticoagulants to prevent thromboembolism&#46; Idiopathic multiple LVAs in a young female demonstrated on ventriculography were reported to be treated conservatively with medical therapy with acceptable clinical course and without adverse clinical sequelae&#46;<a class="elsevierStyleCrossRef" href="#bib0285"><span class="elsevierStyleSup">20</span></a></p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Conclusion</span><p id="par0065" class="elsevierStylePara elsevierViewall">Multiple LVAs in a patient can be idiopathic in nature and have varied presentations&#46; They can be managed conservatively in the absence of angina&#44; decompensated CHF and tachyarrhythmias&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Ethical disclosures</span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Protection of human and animal subjects</span><p id="par0070" class="elsevierStylePara elsevierViewall">The authors declare that no experiments were performed on humans or animals for this study&#46;</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Confidentiality of data</span><p id="par0075" class="elsevierStylePara elsevierViewall">The authors declare that no patient data appear in this article&#46;</p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">Right to privacy and informed consent</span><p id="par0080" class="elsevierStylePara elsevierViewall">The authors have obtained the written informed consent of the patients or subjects mentioned in the article&#46; The corresponding author is in possession of this document&#46;</p></span></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Conflicts of interest</span><p id="par0085" class="elsevierStylePara elsevierViewall">The authors have no conflicts of interest to declare&#46;</p></span></span>"
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        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Multiple left ventricular aneurysms &#40;LVAs&#41; are rare&#44; especially in a young female&#46; A 29-year-old woman presented vague symptoms&#46; Multiple LVAs were revealed and confirmed on different imaging modalities&#44; including chest radiography&#44; echocardiography&#44; contrast ventriculography and cardiac magnetic resonance imaging&#46; Detailed work-up for probable etiologies including ischemic&#44; infectious&#44; inflammatory and autoimmune causes was negative&#46; In the absence of angina&#44; decompensated congestive heart failure&#44; arrhythmias and embolism&#44; the patient was managed conservatively&#44; with excellent mid-term outcome&#46;</p></span>"
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        "resumen" => "<span id="abst0010" class="elsevierStyleSection elsevierViewall"><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">M&#250;ltiplos aneurismas no ventr&#237;culo esquerdo &#40;MAVE&#41; s&#227;o uma situa&#231;&#227;o rara em especial numa jovem que apresentou queixas vagas&#46; V&#225;rios MAVE foram revelados e confirmados em diferentes modalidades de imagem&#46; A doente submeteu-se a radiografia de t&#243;rax&#44; ecocardiografia&#44; ecografia de contraste e resson&#226;ncia magn&#233;tica card&#237;aca&#46; A investiga&#231;&#227;o minuciosa de etiologias isqu&#233;mica&#44; infecciosa&#44; inflamat&#243;ria e autoimune foi negativa&#46; Dada a aus&#234;ncia de angina&#44; insufici&#234;ncia card&#237;aca congestiva&#44; arritmias e embolia&#44; a doente foi tratada de forma conservadora apresentando um excelente progn&#243;stico a m&#233;dio prazo&#46;</p></span>"
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          "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">&#40;A&#41; Chest radiograph in posteroanterior view showing large calcified left ventricular apical aneurysm &#40;&#42;&#41; and basal aneurysm &#40;&#42;&#42;&#41;&#59; &#40;B&#41; electrocardiogram showing no pathological Q waves and normal progression of precordial R wave&#46;</p>"
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          "en" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Transthoracic two-dimensional echocardiogram with color Doppler&#46; &#40;A&#41; Apical 4-chamber view in systole showing apical aneurysm &#40;&#42;&#41;&#59; &#40;B&#41; parasternal long-axis view in diastole showing submitral aneurysm &#40;&#42;&#42;&#41;&#46;</p>"
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          "en" => "<p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Left ventriculogram&#46; &#40;A&#41; Right anterior oblique view in diastole showing apical aneurysm &#40;&#42;&#41;&#44; basal anterior aneurysm &#40;&#42;&#42;&#41;&#44; submitral aneurysm &#40;&#42;&#42;&#42;&#41; and normal left coronary artery branches &#40;arrow&#41;&#59; &#40;B&#41; lateral view in diastole showing LV apical aneurysm &#40;&#42;&#41;&#44; basal anterior aneurysm &#40;&#42;&#42;&#41; and normal left coronary artery branches &#40;arrow&#41;&#46;</p>"
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          "en" => "<p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Cardiac magnetic resonance imaging&#46; &#40;A&#41; Bright-blood image showing apical aneurysm &#40;white arrow&#41; and submitral aneurysm &#40;red arrow&#41; in vertical long-axis view&#59; &#40;B&#41; bright-blood image showing apical aneurysm &#40;white arrow&#41; and anterior aneurysm &#40;yellow arrow&#41; in 4-chamber view&#46;</p>"
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Article information

ISSN: 21742049
Original language: English

DOI:10.1016/j.repce.2016.02.001

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Year/Month	Html	Pdf	Total

2024 November	6	4	10
2024 October	38	38	76
2024 September	60	22	82
2024 August	56	27	83
2024 July	49	29	78
2024 June	66	24	90
2024 May	41	20	61
2024 April	52	28	80
2024 March	46	18	64
2024 February	45	20	65
2024 January	48	23	71
2023 December	46	30	76
2023 November	70	28	98
2023 October	55	14	69
2023 September	51	24	75
2023 August	43	17	60
2023 July	68	12	80
2023 June	45	13	58
2023 May	60	20	80
2023 April	50	5	55
2023 March	50	24	74
2023 February	34	21	55
2023 January	35	10	45
2022 December	52	20	72
2022 November	53	26	79
2022 October	56	15	71
2022 September	31	28	59
2022 August	47	35	82
2022 July	48	29	77
2022 June	39	28	67
2022 May	34	35	69
2022 April	54	23	77
2022 March	37	25	62
2022 February	28	23	51
2022 January	43	25	68
2021 December	30	38	68
2021 November	35	34	69
2021 October	36	32	68
2021 September	24	26	50
2021 August	36	29	65
2021 July	27	27	54
2021 June	30	16	46
2021 May	32	36	68
2021 April	53	25	78
2021 March	81	13	94
2021 February	57	13	70
2021 January	40	13	53
2020 December	37	15	52
2020 November	32	12	44
2020 October	38	23	61
2020 September	52	22	74
2020 August	38	11	49
2020 July	56	6	62
2020 June	40	11	51
2020 May	43	9	52
2020 April	44	11	55
2020 March	45	10	55
2020 February	128	44	172
2020 January	25	8	33
2019 December	34	9	43
2019 November	37	8	45
2019 October	28	6	34
2019 September	76	14	90
2019 August	40	3	43
2019 July	35	9	44
2019 June	43	8	51
2019 May	52	6	58
2019 April	41	15	56
2019 March	43	11	54
2019 February	37	7	44
2019 January	47	5	52
2018 December	41	13	54
2018 November	205	11	216
2018 October	575	27	602
2018 September	124	10	134
2018 August	84	3	87
2018 July	49	3	52
2018 June	72	5	77
2018 May	85	7	92
2018 April	124	21	145
2018 March	70	21	91
2018 February	25	3	28
2018 January	30	8	38
2017 December	44	3	47
2017 November	50	19	69
2017 October	34	11	45
2017 September	43	16	59
2017 August	30	9	39
2017 July	24	13	37
2017 June	47	9	56
2017 May	50	7	57
2017 April	44	4	48
2017 March	48	11	59
2017 February	39	6	45
2017 January	33	2	35
2016 December	29	15	44
2016 November	23	2	25
2016 October	30	7	37
2016 September	36	14	50
2016 August	9	7	16
2016 July	14	3	17
2016 June	7	4	11
2016 May	12	5	17
2016 April	7	1	8
2016 March	32	29	61

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