Heart

2. Findings and Diagnosis

 

• • Editorial Comment:
    • The shape of the LV apex is key in distinguishing between a true aneurysm and a pseudoaneurysm:
      • True LV aneurysm: Wide neck, thin but intact myocardium, rounded shape
      • Pseudoaneurysm: Narrow neck, rupture contained by pericardium, risk of rupture

1. A 68-year-old male with a history of a remote anterior myocardial infarction presents with exertional dyspnea. A CT scan reveals a thin-walled, dyskinetic, bulging structure at the apex of the left ventricle. What is the most likely diagnosis?

A) Left ventricular apical aneurysm
B) Left ventricular pseudoaneurysm
C) Hypertrophic cardiomyopathy
D) Left ventricular thrombus
E) Cardiac sarcoidosis

✅ Correct Answer: A) Left ventricular apical aneurysm

Explanation:

• LV aneurysms occur after an infarction, leading to thinned, dyskinetic myocardium with a broad neck and a persistent bulge.
• They are commonly seen in the apex following anterior MI.

❌ Incorrect Answers:

• B) LV pseudoaneurysm → Incorrect because pseudoaneurysms have a narrow neck and are caused by contained rupture, often with a high rupture risk.
• C) Hypertrophic cardiomyopathy → Incorrect because HCM presents with myocardial thickening, not a thin-walled bulge.
• D) LV thrombus → Incorrect because thrombus appears as an echogenic filling defect within the LV, often inside an aneurysm but not an aneurysm itself.
• E) Cardiac sarcoidosis → Incorrect as sarcoidosis can cause granulomatous myocarditis but does not form an apical aneurysm.

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2. Which of the following best differentiates a left ventricular aneurysm from a left ventricular pseudoaneurysm?

A) Aneurysms have a narrow neck, while pseudoaneurysms have a wide neck
B) Aneurysms are at high risk of rupture, while pseudoaneurysms are more stable
C) Aneurysms have a wide neck and contain myocardium, while pseudoaneurysms have a narrow neck and lack myocardium
D) Both conditions have the same rupture risk
E) Both conditions require urgent surgical repair

✅ Correct Answer: C) Aneurysms have a wide neck and contain myocardium, while pseudoaneurysms have a narrow neck and lack myocardium

Explanation:

• True aneurysms have a wide neck and consist of thinned but intact myocardium.
• Pseudoaneurysms have a narrow neck and result from a ruptured ventricular wall contained by the pericardium, making them high risk for rupture.

❌ Incorrect Answers:

• A) Aneurysms have a narrow neck → Incorrect. Aneurysms have a wide neck; pseudoaneurysms have a narrow neck.
• B) Aneurysms are at high risk of rupture → Incorrect. Pseudoaneurysms have a higher rupture risk.
• D) Both have the same rupture risk → Incorrect. Pseudoaneurysms rupture more often because they lack a full myocardial wall.
• E) Both require urgent surgical repair → Incorrect. Pseudoaneurysms require surgery; aneurysms often do not unless symptomatic.

Key Takeaways:

• LV aneurysms have a wide neck and contain thinned myocardium.
• Pseudoaneurysms have a narrow neck, lack myocardium, and are at high risk for rupture.
• Main complication of LV aneurysms = LV thrombus → embolic events.