Diagnosis Of Left Ventricular Aneurysm Research Articles

Right ventricular visualization at SPECT perfusion imaging before and after revascularization in patients with postinfarction cardiosclerosis

Aim. To evaluate the intersystemic (between the myocardium of the left coronary artery system and the right coronary artery system redistribution mechanisms of perfusion in the myocardium after revascularization in patients with coronary artery disease with focal cardiosclerosis using gated single photon emission computed tomography. Сardiosclerosis foci were initially identified by magnetic resonance imaging. Material and Methods. The study included 17 patients with coronary artery disease with multivessel coronary disease and large-focal cardiosclerosis according to the results of magnetic resonance imaging with contrast; the diagnosis of left ventricular aneurysm was established in 14 patients, the focal subendocardial cardiosclerosis was diagnosed in 3 patients. For various reasons, all patients underwent myocardial revascularization without the left ventricle reconstruction (coronary artery bypass grafting in 10 patients, percutaneous coronary intervention in 7 patients). Magnetic resonance imaging was used as the gold standard for focal cardiosclerosis before revascularization. All patients before and after revascularization underwent gated single photon emission computed tomography with MIBI scan. During the initial analysis of peaks on the profile slices of coronal and transversal midsections passing along the lateral walls of the left and right ventricles, we did not notice a clear visualization of in 8 patients (group 1), while an increased MIBI scan accumulation in the right ventricle myocardium was clearly visualized in 9 patients (group 2). Based on the peaks height of profile curves, we compared changes in the maxima of radiopharmaceutical accumulation before and after revascularization in the lateral walls of the left ventricle and right ventricle. All studies were performed using the original Cardiac Functional Imaging medical program in order to obtain quantitative information about the myocardial function of both the left ventricle, and also the right ventricle. This program made it possible to highlight the right ventricle area even in the case of its weak visualization through the initial formation of parametric images, where the right ventricle area was visualized. Results. When comparing the revascularization results of the two groups, we noted that the left ventricle ejection fraction increased significantly only in patients without initial visualization of the right ventricular myocardium. Left ventricle ejection fraction did not change after revascularization in patients with initially increased accumulation of the radiopharmaceutical in the right ventricle. Globally, only an improvement in the diastolic function of the left and right ventricles was noted in the latter group of patients. In addition, an increase in the right ventricular uptake level was noted for patients with focal cardiosclerosis and the initially increased uptake in the right ventricle after the maximum possible complete myocardial revascularization, which may indicate a redistribution of perfusion in favor of a more intact right ventricular myocardium. Conclusions. 1. In patients without signs of increased visualization of the right ventricle (group 1) after revascularization, we revealed a statistically significant increase in the left ventricle ejection fraction (p-value=0.024), a decrease in the end-systolic volume (p-value=0.024), an increase in the motion in segments corresponding to the peri-infarct scar zone (p-value=0.016), and a change in systolic thickening in the segment of the basal parts of the anterolateral wall (p-value=0.046). 2. Initially increased visualization of the right ventricle in patients with extensive focal cardiosclerosis in the myocardium of the left ventricle suggests the absence of the left ventricle ejection fraction increase after myocardial revascularization. 3. An increase in the visualization of the right ventricle after complete myocardial revascularization indicates an intersystemic redistribution of perfusion in favor of the preserved myocardium of this part of the heart.

Double-chambered left ventricle: diagnosis by CMR and review of the literature

BackgroundA double-chambered left ventricle (DCLV) is an extremely rare congenital malformation. The exact prevalence of DCLV is not known, although studies have reported prevalence of 0.04–0.42%. This abnormality is characterized by the sub-division of left ventricle into two chambers, the main left ventricular chamber (MLVC) and the accessory chamber (AC) by a septum or muscle band.Case presentationWe are reporting two cases of DCLV, one in an adult male and an infant, who were referred for undergoing cardiac magnetic resonance (CMR) imaging. The adult patient was asymptomatic, whereas the infant had the diagnosis of left ventricular aneurysm on fetal echocardiography. On CMR, we confirmed the diagnosis of DCLV in both patients, as well as moderate aortic insufficiency in the adult patient. Both patients were lost to follow-up.ConclusionsThe double-chambered left ventricle (DCLV) is commonly detected in infancy or childhood. Although echocardiography can help detect double-chambered ventricles, MRI provides a better knowledge of this problem and can also be used to diagnose other related heart disorders.

Multimodal Visualization of the Left Ventricular Postinfarction Aneurysms: Current State of the Problem and Own Observation Results

Background. Left ventricular aneurysm (LVA) is a complication occurring in 5–10% of acute myocardial infarction (AMI) patients significantly complicating AMI acute stage course and leading to advanced congestive heart failure (CHF) progress. Non-invasive LVA visualization includes echocardiography, cardiac magnetic resonance imaging (MRI), radio-nuclide ventriculography, and multi-slice computed tomography (MSCT). It can also be detected during heart catheteriza-tion by coronary ventriculography (CVG). Each method has its advantages and drawbacks.
 The aim. To analyze multimodal non-invasive LVA visualization methods (echocardiography and MSCT) in order to establish accuracy of these methods compared to CVG regarding the diagnosis of LVA and LVA thrombosis.
 Methods. We examined 60 patients after AMI with LVA admitted for surgical revascularization and left ventricular aneurysm resection (LVAR). Control group included 110 patients after AMI prior to revascularization without history of LVA. All the patients underwent CVG, heart MSCT and echocardiography prior to surgery.
 Results. Mean patients’ age was 60.9±11.4 years (46 [76.7%] men and 14 [23.3%] women, mean LVEF was 42.7±11.1%. Significant CAD according to coronary angiography (CAG) before surgery was proved in 59 (98.3%) pa-tients, and 1 (1.7%) patient had no significant coronary lesions. The majority of patients had anterior LVA localization after AMI in LAD area (57 [95.0%] patients), 2 (3.3%) patients were diagnosed with inferior LVA after AMI in RCA area, and 1 (1.7%) patient had posterior-lateral LVA in Cx area. There was high correlation between LVEF obtained with echo-cardiography and that obtained with MSCT (r=0.955, p<0.0001), although mean LVEF obtained with echocardiography was significantly higher compared to MSCT results (42.7±11.1% vs. 32.7±9.3%, p<0.0001). Comparison of accuracy of the methods in LVA diagnosis showed that MSCT was the most precise method with significantly higher sensitivity compared to CVG and echocardiography (94.9% vs. 75.0%, p=0.002, and 88.0%, p=0.023, respectively), and MSCT significantly ex-ceeded CVG in all diagnostic method accuracy indices. Echocardiography also significantly exceeded CVG in all diagnostic accuracy indices. Comparison of accuracy of the methods in LVA thrombosis diagnosis showed similar results: echocar-diography was much more precise in terms of sensitivity (79.4% vs. 58.8%, p<0.0001) and the rest of indices. MSCT was much more precise in terms of all indices compared to CVG, and also significantly exceeded echocardiography results in terms of sensitivity (97.1% vs. 79.4%, p<0.0001), positive (PPV) (100.0% vs. 93.1%, p=0.0005) and negative predictive value (NPV) (99.1% vs. 93.9%, p=0.0091), integral “area under curve” index (AUC) (0.99 vs. 0.89, p=0.0001) and odds ratio (OR) (3630 vs. 208, p<0.0001).
 Conclusions. High correlation of LVEF according to echocardiography and MSCT results allows to skip CVG as a global LV contractility evaluation method enabling to reduce the procedure time. The lowest accuracy of CVG in the diagnosis of LVA and LVA thrombosis also allows to reduce the duration and volume of the invasive procedure to selective CAG and to reduce radiation exposure for patients and operators in favor of non-invasive and more accurate methods (MSCT and echocardiography). MSCT is the most accurate method for LVA thrombosis diagnosis, but it is completely comparable to echocardiography in LVA diagnosis per se, making echocardiography the method of choice in screening and stratification of patients after AMI regarding myocardial revascularization only or combined surgical revascularization with LVAR due to its rapidness, low cost and absence of patient-related adverse effects.

Congenital left ventricular aneurysms and diverticula: an entity in search of an identity.

Congenital left ventricular aneurysm or diverticulum are rare cardiac malformations described in 809 cases since the first description in 1816, being associated with other cardiac, vascular or thoraco-abdominal abnormalities in about 70%. It appears to be a developmental anomaly, starting in the 4th embryonic week. In an experimental study, targeted knockdown of cardiac troponin T in the chick was performed at day 3, after the heart tube has formed. Morpholino treatment of gene TNNT2 at this stage led to the development of left ventricular diverticula (LVD) in the primitive left ventricular wall. Diagnosis of left ventricular aneurysms (LVA)/LVD can be made after exclusion of coronary artery disease, local or systemic inflammation or traumatic causes as well as cardiomyopathies. Clinically, most of LVA and LVD are asymptomatic or may cause systemic embolization, congestive heart failure, valvular regurgitation, ventricular wall rupture, ventricular tachycardia or sudden cardiac death. Diagnosis is established by imaging studies (echocardiography, magnetic resonance imaging or left ventricular angiography) visualizing the structural changes and accompanying abnormalities. Mode of treatment has to be individually tailored and depends on clinical presentation, accompanying abnormalities and possible complications, options include surgical resection (especially in symptomatic patients), anticoagulation after systemic embolization, radiofrequency ablation or implantation of an implantable cardioverter defibrillator (ICD) in case of symptomatic ventricular tachycardias, and occasionally combined with class I- or III-antiarrhythmic drugs. Cardiac death occurs usually in childhood, is significantly more frequent in LVA patients and caused by congestive heart failure in most of the cases, whereas patients diagnosed with LVD died more frequently from rupture of the LVD.

Prevalence and Spectrum of Coronary Artery Anomalies in Patients With an Isolated Congenital Left Ventricular Aneurysm or Diverticulum

Congenital left ventricular aneurysm (LVA) and diverticulum (LVD) are rare cardiac anomalies and frequently associated with other cardiac anomalies. The objective of our study was to investigate the prevalence and the spectrum of coronary anomalies in such patients. The incidence of coronary anomalies is increased in patients with LVA or LVD. We assessed 117 patients with isolated LVA or LVD for the prevalence of coronary anomalies and compared the findings with an age- and sex-matched control group (n = 117) without the diagnosis of LVA or LVD. Coronary anomalies were present in 58.1% of the study population (68 of 117). The median age of affected patients was 64 years, and 45 (38.5%) were male. Coronary anomalies were more prevalent in patients with LVA or LVD (58.1% vs 6.8%, P < 0.001), male patients (89% vs 57%, P = 0.0002), and in patients with nonapical location of LVA or LVD (24% vs 45%, P = 0.02) compared with control, whereas age and type (LVA vs LVD) had no influence (57% vs 57.6%, P = 0.4; and 58.8% vs 57.6%, P = 0.87, respectively). The number of adverse cardiac events was similar in both groups during a 4.2-year follow-up period (29% vs 19%, P = 0.09). None of the patients in our series had major coronary anomalies with potential lethal consequences. This large single-center study suggests that the prevalence of abnormal coronary-artery anatomy in patients with isolated LVA or LVD is as high as 58.1%. However, we did not identify major coronary anomalies with potential lethal consequences, and the clinical course during follow-up was not influenced by the presence or absence of coronary anomalies.

Prenatal diagnosis of left ventricular aneurysm in association with interruption of the aortic arch

Left ventricular aneurysms in the foetus are a rare abnormality that can occur in isolation or associated with pentalogy of Cantrell. Here, we report a case of a foetus with a left ventricular aneurysm in association with interruption of the aortic arch, and no features of pentalogy of Cantrell. To our knowledge, this is the first report of such an association.

Chronisches Ventrikelaneurysma: Sensitivität und Spezifität persistierender ST-T-Elevationen im Elektrokardiogramm

The value of persistent ST-T elevations in the standard 12-lead ECG for the diagnosis of left-ventricular aneurysm (VA) was retrospectively analysed for 200 patients (171 males and 29 females) who had sustained a myocardial infarction at least 12 weeks previously. 105 patients (group 1) had a left-ventricular aneurysm confirmed by ventriculography; in 95 patients (group 2) an aneurysm had been excluded by ventriculography. Persistent ST-T elevations were present in 98 patients of group 1 (sensitivity 93.3%) and in 26 of group 2 (specificity 72.6%). In the 26 patients without VA, ST-T elevations occurred in at most three leads, but in 60 with aneurysm in four to nine leads. In addition, the area under the ST-T elevations and its height 1 mm after onset of the elevation and its maximal height were measured. The sums of the values in the limb and chest leads were statistically significantly different between the two groups for all three parameters. These measurements thus contribute to a reliable differentiation between patients with and without VA. The results also emphasize the importance of the 12 standard leads in the diagnosis of VA.

Left ventricular aneurysm: comprehensive assessment of morphology, structure and thrombus using cardiovascular magnetic resonance

To demonstrate that cardiac magnetic resonance (CMR) techniques provide unique and definitive information on the presence, location, size and nature of left ventricular aneurysm and pseudoaneurysm, the presence of thrombus and the viability of myocardium. A retrospective study of 27 patients with a final diagnosis of left ventricular aneurysm or pseudoaneurysm, who underwent CMR at a tertiary referral centre in the period between 2000 and 2003. In 7 cases the correct diagnosis of true aneurysm was confirmed; in 7 cases previously unsuspected thrombus was identified; in 7 cases an unsuspected pseudoaneurysm was identified; and in a further 6 cases a previously unsuspected aneurysm was identified. CMR refined the diagnosis in the majority of patients with left ventricular aneurysm, and should be considered in all cases of confirmed or suspected left ventricular aneurysm.

Electrocardiographic ST segment elevation: Left ventricular aneurysm

Left ventricular aneurysm (LVA), also described as dyskinetic left ventricular segment, is defined as a localized area of infarcted myocardium that bulges outward during both systole and diastole. LVAs most often are noted after large anterior wall events but may also be encountered status after inferior and posterior wall injuries. In most cases, LVA is manifested electrocardiographically by varying degrees of ST segment elevation (STE), which may be difficult to distinguish from ST segment changes caused by acute myocardial infarction. The STE is generally associated with well-developed, completed Q waves in the anterior precordial leads, and there will not be reciprocal ST depression in the contralateral leads. This article focuses on the electrocardiographic findings useful in making the diagnosis of left ventricular aneurysm as well as distinguishing LVA from other STE syndromes. (Am J Emerg Med 2002;20:238-242. Copyright 2002, Elsevier Science (USA). All rights reserved.)

Prenatal diagnosis of left ventricular aneurysm: a report of three cases and a review.

We report three cases of left ventricular aneurysm diagnosed prenatally and followed by fetal Doppler echocardiography. A review of the literature reveals a paucity of information about this rare cardiac malformation. Most of the described cases (6 out of 9) have remained asymptomatic during pregnancy and after birth. Our cases, in contrast, and three others in the literature, had an ominous prognosis presenting cardiac failure initially or during follow up and showing a dynamic evolution of the aneurysm. Cross-sectional echocardiography provides the diagnosis, revealing the thin-walled aneurysm, usually apical, to be connected by a broad neck to the left ventricle. Color and pulsed Doppler shows low velocity and to-and-fro flow in the aneurysm. Sequential fetal Doppler echocardiography detects the potential growth of the aneurysm relative to ventricular size, revealing any compromise of cardiac performance by a decreased mitral opening, reversed atrial shunting, a hypokinetic infero-posterior left ventricular wall, and a poor systolic thickening of the wall of the aneurysm. Compromise of cardiac function, and deleterious impact on development of the lungs during fetal life, may depend on the early onset, growth and location of the aneurysm,which may occupy most of the fetal chest. We discuss issues of prenatal diagnosis, sequential surveillance of the natural history, and factors of prognosis as well as myocardial histological data from one of our cases.

Disappearance of a Left Ventricular Aneurysm on Radionuclide Ventriculography due to Formation of a Mural Thrombus

Radionuclide ventriculography is an accepted method for diagnosing left ventricular aneurysms, but false-negative studies have been associated with a mural thrombus filling the left ventricular cavity. We describe a patient with a left ventricular aneurysm due to myocardial infarction whose aneurysm scintigraphically "disappeared" from serial radionuclide ventriculograms. This was documented echocardiographically and pathologically to be due to the formation of a large mural thrombus. Review of the literature suggests that radionuclide ventriculography and echocardiography may be complementary techniques in the diagnosis of left ventricular aneurysm. Echocardiography may remain diagnostic when a mural thrombus has caused the loss of the characteristic scintigraphic findings on radionuclide ventriculography.

THE “BLACK HOLE” SIGN OF LEFT VENTRICULAR ANEURYSM IN Tl-201 SPECT IMAGES

Fifty-three of 83 patients with transmural perfusion defects had a “black hole” within the left ventricle on Tl-201 SPECT images. A “black hole” was defined as a focal, oval area of no activity within the left ventricular cavity adjacent to the transmural perfusion defect. 30 patients had only transmural perfusion defects with no “black hole”. Transmural defect is defined as an area of decreased perfusion with activity equal to or less than background. All had contrast ventriculography and/or echocardiography or gated blood pool studies. Fifty out of 53 patients with a “black hole”, and one out of 30 patients with only a transmural defect had left ventricular aneurysm. Of these 50 true positives, 13 had parallel, 10 had converging and 27 had a diverging configuration of the left ventricle walls towards the apex. In the three false positives two had parallel and one had converging left ventricle walls. The criterion of a “black hole” for the diagnosis of left ventricular aneurysm in patients with transmural myocardial perfusion defect had a 98% sensitivity, 91% specificity, 95% accuracy and 94% predictive value. Combining the criterion of diverging configuration of left ventricle walls with transmural perfusion defect and a “black hole” increased the predictive value for left ventricular aneurysm to 100%. Thus the “black hole” sign in Tl-201 SPECT images is highly accurate in the diagnosis of left ventricular aneurysm.

Echocardiographic-cineangiographic correlation in detecting left ventricular aneurysm: A prospective study of 422 patients

Four hundred twenty-two consecutive patients with a documented myocardial infarction underwent cardiac catheterization and echocardiographic examination. Adequate two dimensional echocardiograms were obtained in 386 patients (91 percent). Left ventricular aneurysm was defined echocardiographically and cineangiographically as a well demarcated bulge in the contour of the left ventricular wall during both diastole and systole, demonstrating dyskinesia or akinesia. Cineangiography was considered as the standard for the diagnosis of left ventricular aneurysm. The site of aneurysm was mainly anteroapical. An aneurysm was judged present on cineangiography in 111 patients and on echocardiography in 118 patients. The presence and absence of an aneurysm echocardiographically correlated in 103 and 260 patients, respectively, with cineangiography. In 8 patients a cineangiographically identified aneurysm was not manifested echocardiographically, whereas in 15 patients an aneurysm identified on echocardiography was not evident on cineangiography. Thus two dimensional echocardiography can detect or exclude a left ventricular aneurysm with a high level of sensitivity (93 percent) and specificity (94 percent).

Clinical recognition of giant left ventricular aneurysm

The noninvasive diagnosis of left ventricular aneurysm has markedly improved with gated blood pool scintigraphy. However, in patients with giant anterior ventricular aneurysms, the gated blood pool scintigram performed in two standard views (anterior and 40 degree left anterior oblique) may incorrectly suggest ischemic cardiomyopathy. We retrospectively identified five patients who underwent resection of a ventricular aneurysm over a 2 1 2 year period and who had preoperative scintigraphic studies that appeared to show severe diffuse left ventricular dysfunction. Contrast ventriculography demonstrated preserved wall motion in septal, inferior and lateral segments not seen by gated blood pool scintigraphy and showed extraordinarily large anterior aneurysms. M-mode or two-dimensional echocardiograms showed intact posterior wall function in all patients, suggesting severe regional myocardial disease rather than global dysfunction. Two-dimensional echocardiography showed additional segments with preserved function as well as discrete aneurysms in all patients. We conclude that gated blood pool scintigraphy, when performed in two standard views, may fail to correctly diagnose some patients with very large anterior wall aneurysms. M-mode echocardiography, two-dimensional echocardiography and additional scintigraphic views that visualize the posterior portions of the left ventricle improve noninvasive diagnosis of patients with resectable giant left ventricular aneurysms.

Radiographic visualization of left ventricular aneurysms on lateral chest film

The diagnosis of left ventricular aneurysm on routine chest examination can be elusive. Six cases are presented which illustrate a radiographic sign not previously emphasized: a soft tissue border seen retrosternally or superiorly on lateral chest film produced by the wall of the aneurysm silhouetting against the midline cardiac shadow. This sign is not always present since it is dependent on the direction of projection of the aneurysm. However, when observed, it should suggest the proper diagnosis.

Aneurysmectomy in treatment of ventricular and supraventricular tachyarrhythmias in patients with postinfarction and traumatic ventricular aneurysms

Serious, refractory or recurrent, or both, paroxysmal tachyarrhythmia occurred in 8 of 33 consecutive patients with a diagnosis of left ventricular aneurysm established by angiocardiography. The arrhythmia was ventricular in origin in five patients and supraventricular in three. Six of the eight patients were operated upon and the aneurysms resected. Four patients survived the operation and had no recurrence of the arrhythmias during a follow-up period of 7 to 25 months. One of these patients had a traumatic myocardial aneurysm associated with ventricular tachyarrhythmia. The other three patients had postinfarction aneurysms; ventricular tachycardia had been present in two and recurrent atrial flutter in the third. Two patients died after operation. They differed from the surviving patients in that they both had three-vessel coronary artery disease and severe impairment of myocardial contractility. Two patients responded satisfactorily to medical treatment so that surgery was not considered necessary. One of these had a postinfarction aneurysm and ventricular tachycardia that recurred less frequently with antiarrhythmic therapy. The other had a traumatic myocardial aneurysm and supraventricular tachycardia that was adequately controlled with drugs. Aneurysmectomy should be considered in the management of patients with postinfarction or traumatic ventricular aneurysms who present with refractory ventricular or supraventricular tachycardia.