Multimodality Cardiac Imaging for the Assessment of a Left Ventricular Pseudoaneurysm in a Transplanted Heart

Abstract

A 63-year-old female two years post orthotopic heart transplant initially presented with pneumonia. Subsequent CT-chest (Figure 1) revealed a mass on the anterior surface of the heart. Transthoracic echocardiography (Figure 2,3) demonstrated blood flow via a sinus between the mass and left ventricle and this was confirmed following administration of echo contrast. Cardiac-MRI (Figure 4) revealed a mid-anteroseptal pseudoaneurysm cavity with swirling motion within the aneurysm measuring 26 mm transverse x 20 mm craniocaudal x 30 mm anteroposterior. CT-aortography revealed the three dimensional structure of the mass. Intraoperative inspection confirmed the presence of a LV pseudoaneurysm (Figure 5). Background: Most aneurysms of the left ventricle are true aneurysms occurring with dilation and scarring of the left ventricular wall. However, this is a case of a pseudoaneurysm arising from the left ventricle in a patient two years post cardiac transplantation for familial dilated cardiomyopathy. Due to its thin and disorganised wall structure, a pseudoaneurysm is predisposed to spontaneous rupture. No definitive cause for the pseudoaneurysm was found but it was suspected to be iatrogenic at the time of transplantation. Conclusion: The diagnosis of a pseudoaneurysm requires expedited management with cardiac surgery. This case exemplifies the importance of multimodality imaging assessment and emphasises timely multidisciplinary collaboration to optimise diagnosis and management.