• A pseudoaneurysm, or false aneurysm, of the right ventricle is a contained rupture where the myocardial wall is breached, but the blood is held in by surrounding pericardium or scar tissue.
• Unlike a true aneurysm, its wall does not contain myocardial tissue and it typically communicates with the ventricle through a narrow neck.

Comment

• Right ventricular pseudoaneurysms are rare and life-threatening due to a high risk of fatal rupture.
• Common causes include myocardial infarction, trauma, infection, and complications from cardiac surgery.
• CT and echocardiography are the primary imaging modalities used for diagnosis.

Citation

• (Hulten E, Circulation, 2012

• Pericardial calcification is the deposition of calcium within the pericardium, the sac surrounding the heart, typically resulting from chronic inflammation, scarring, or tissue death.

Comment

• It is often an incidental finding on CT scans performed for other reasons.
• Common causes include previous viral or tuberculous pericarditis, cardiac surgery, trauma, radiation, and malignancy.
• While it is a key finding in many cases of constrictive pericarditis, calcification can be present without constriction, and constriction can occur without calcification.

Citation

• (Ling L, QJM, 2013)

• Pericardial thickening refers to an increase in the thickness of the pericardium, which can occur in inflammatory and non-inflammatory conditions.

Comment

• On CT, the normal pericardium is typically less than 2 mm thick.
• A thickness of 4 mm or greater is considered abnormally thick, while 2-3 mm is equivocal.
• Pericardial thickening can be diffuse and uniform or focal and nodular.

Citation

• (Breen JF, Radiographics, 2004)

• Right atrial enlargement is an abnormal increase in the size of the right atrium, typically caused by conditions that increase pressure or blood volume within the chamber.

Comment

• On axial CT images, the right atrium can be considered enlarged when its transverse diameter is ≥67 mm in males or ≥64 mm in females.
• This transverse (short axis) measurement is typically taken from the interatrial septum to the free wall of the right atrium at its widest point.
• Other measurements, such as a major (long) axis greater than 5.3 cm, can also indicate enlargement.

Citation

• (Poutanen T, Radiopaedia.org, 2025)

• A pseudoaneurysm is a contained rupture of the myocardium, characterized by a breach in the myocardial wall contained by a tenuous wall of fibrous tissue and pericardium, lacking myocardial components in its own wall.
• It is distinct from a true aneurysm, which involves all three layers of the vascular wall.

• Post-pericardiectomy pseudoaneurysms can arise from various etiologies, including complications from cardiac surgery, trauma, or infection.
• Specifically, iatrogenic causes related to procedures such as pericardiocentesis have been implicated in pseudoaneurysm formation.
• Surgical interventions, including sternotomy and the use of sternal wires, can also lead to pseudoaneurysm development.

• The pathophysiology involves an injury to the myocardial wall leading to a contained leak.
• This leak is contained by a newly formed, albeit weaker, wall composed of fibrin and platelet crosslinks.
• In the context of post-pericardiectomy complications, the inflammatory process and tissue damage following surgery can predispose to such a contained rupture.

• A pseudoaneurysm results in a sac-like structure that communicates with the cardiac chamber through a narrow neck.
• The wall of the pseudoaneurysm is composed of external fibrous tissue and pericardium, rather than myocardial tissue.

• Pseudoaneurysms can compromise ventricular stroke volume due to the abnormal blood flow dynamics within the pseudoaneurysmal sac.
• They can also serve as a source of thromboembolism to vital organs.

• Multimodality imaging is crucial for diagnosis.
• Echocardiography, particularly transesophageal echocardiography, can visualize the pseudoaneurysm, though its effectiveness can be limited by echo window quality.
• Cardiac computed tomography (CT) and cardiac magnetic resonance (CMR) imaging are considered gold standards for characterization, with CT offering high spatial resolution and CMR providing excellent tissue characterization.
• Delayed intense pericardial enhancement on MRI can be a significant indicator.
• Contrast-enhanced CT is often the modality of choice for definitive diagnosis due to its speed and availability.

• Laboratory findings are not specific for pseudoaneurysm itself but may reflect underlying inflammatory processes such as postpericardiotomy syndrome, which can include elevated C-reactive protein (CRP) and erythrocyte sedimentation rate (ESR), as well as leukocytosis with a leftward shift.
• Blood cultures should be negative to rule out active infection.

• The definitive treatment for cardiac pseudoaneurysms is typically surgical intervention due to the high risk of rupture associated with untreated pseudoaneurysms.
• Surgical options include excision and repair, often with the use of patch materials such as Dacron or bovine pericardium, and may involve cardiopulmonary bypass.
• Endovascular repair may also be considered in select cases.
• For smaller pseudoaneurysms, observation may be an option, but given the potential for catastrophic rupture, definitive management is often preferred.

• Untreated pseudoaneurysms carry a high mortality rate, approaching 50%.
• Early diagnosis and prompt treatment are critical determinants of outcome.
• If the patient is young, has no significant comorbidities, and preserved cardiac function, surgical repair can be curative.
• Long-term outcomes after surgical repair are generally good, although the specific prognosis depends on the underlying etiology, extent of cardiac damage, and technical success of the repair.

• While myocardial infarction is a common cause of pseudoaneurysms, in the specific context of a post-pericardiectomy patient, the surgical site is a more direct cause than a new infarct.

• A pseudoaneurysm is a contained cardiac rupture. Following surgery, chronic inflammation and scarring can weaken the heart wall, leading to a contained rupture where blood is walled off by the pericardium or scar tissue.

• While the initial injury may occur during surgery, the formation of a pseudoaneurysm is typically a delayed process resulting from impaired healing, not an immediate, overt rupture.

• Infection can cause pseudoaneurysms, but the fundamental mechanism is still a breach and containment of the cardiac wall, not simply erosion.

• Atherosclerosis is a primary cause of true aneurysms, particularly of the aorta, not typically post-surgical cardiac pseudoaneurysms.

• Myocardial infarction can cause a pseudoaneurysm, but in a post-surgical setting, the injury is more directly related to the procedure itself.

• A pseudoaneurysm is, by definition, a rupture of the heart wall where the leaking blood is contained by adjacent structures like the pericardium or scar tissue, not the heart muscle itself.

• An autoimmune response can cause postpericardiotomy syndrome, an inflammatory condition, but it does not directly cause the structural breach required for a pseudoaneurysm.

• While mitral regurgitation can occur, it is a secondary complication and not as immediately life-threatening as the primary risk.

• The wall of a pseudoaneurysm is composed of pericardium or scar tissue, not durable myocardium, creating a high risk of catastrophic rupture (30-45%), which can lead to rapid hemodynamic collapse and death.

• Thrombus formation and subsequent embolization are significant risks, but the risk of acute rupture is the most critical immediate concern.

• Constrictive pericarditis results from chronic pericardial inflammation and scarring and is not a direct complication of a pseudoaneurysm itself.

• Hemoptysis is not a typical symptom of a cardiac pseudoaneurysm.

• Stagnant blood flow within the pseudoaneurysm sac often leads to the formation of thrombi (clots). These clots can break off and travel through the bloodstream, causing blockages in distant organs (e.g., stroke).

• These are classic signs of cardiac tamponade (fluid accumulation in the pericardial sac), which is a different condition.

• This is inflammation of the gallbladder and is unrelated to a cardiac pseudoaneurysm.

• Chest X-ray is non-specific and may only show an enlarged cardiac silhouette.

• TTE is often the initial test, but its ability to definitively diagnose and fully characterize a pseudoaneurysm can be limited, especially in post-surgical patients.

• CMR provides excellent detail and tissue characterization but may be less available and slower than CT, which is often critical for surgical planning in these potentially unstable patients.

• CTA is often considered the modality of choice as it offers rapid, high-resolution imaging that clearly delineates the pseudoaneurysm’s anatomy, its neck, and its relationship to surrounding structures, which is crucial for diagnosis and planning surgery.

• The wall of a pseudoaneurysm is typically thin and tenuous, composed of pericardium or scar tissue.

• This describes a true aneurysm. A pseudoaneurysm involves a rupture through all three wall layers.

• A key differentiator is that a pseudoaneurysm’s wall lacks myocardial tissue and it communicates with the cardiac chamber via a narrow neck, whereas a true aneurysm is a wide-mouthed bulge of all existing wall layers.

• While thrombus is common in pseudoaneurysms, the sac is not always completely filled.

• These findings describe the nature of the pseudoaneurysm wall itself, which is composed of scar and fibrous tissue, not an active infarction.

• Acute pericarditis is a diffuse inflammation of the pericardium and presents with different imaging characteristics than the wall of a pseudoaneurysm.

• The thin, non-contractile nature and delayed enhancement on CMR are characteristic features of the fibrous/scar tissue that forms the wall of a pseudoaneurysm, confirming the absence of healthy, contracting heart muscle.

• While thrombus is often present, these specific imaging findings (non-contractility and delayed enhancement) describe the wall of the sac, not the clot within it.