Multi-Image Studies of Atypical Location of Ventricular Aneurysms and Survival: Clinical Cases Series

Background: A left ventricular aneurysm is a mechanical complication of a myocardial infarction that frequently develops on the anterior and apical wall. Survival of 3 to 5 years is 27% and 12%, respectively. Our objective is to report 3 cases of ventricular aneurysms in atypical locations and analyze the survival of these patients. Material and Methods: Three patients with suspicion of ventricular aneurysm after acute myocardial infarction who sought attention at our institution were included. All underwent transthoracic echocardiograms (TTE), cardiac magnetic resonance (CMR), nuclear cardiology (NC), coronary angiotomography and cardiac catheterization to assess the location and characteristics of the aneurysms, left ventricular systolic function and the anatomical and functional condition of the coronary arteries. Results: The mean age of studied patients was 58.33 ± 10.37 years. The locations of the ventricular aneurysms were lateral, inferior and septal. The patients received optimal medical treatment to control heart failure and were discharged in stable condition without early mortality. The mean follow-up was 6.33 years (intervals: 2 9) and during this period the patients were in NYHA functional class I/II. Conclusion: Left ventricular aneurysm is a late mechanical complication of an infarction that can develop in an atypical location. Diagnosis is achieved using non-invasive techniques such as TTE, CMR, NC, and coronary angiotomography. No mortality occurred among the patients during medium and long-term follow-up. How to cite this paper: Camacho-Camacho, G., Carvajal-Juárez, I., Guatibonza-Zambrano, H., de la Torre, A., Meave-Gonzalez, A., Keirns, C., Alexanderson-Rosas, E., Flores-García, A. and Espinola-Zavaleta, N. (2019) Multi-Image Studies of Atypical Location of Ventricular Aneurysms and Survival: Clinical Cases Series. World Journal of Cardiovascular Diseases, 9, 524-537. https://doi.org/10.4236/wjcd.2019.98045 Received: July 4, 2019 Accepted: August 10, 2019 Published: August 13, 2019 Copyright © 2019 by author(s) and Scientific Research Publishing Inc. This work is licensed under the Creative Commons Attribution International License (CC BY 4.0). http://creativecommons.org/licenses/by/4.0/


Introduction
Left ventricular aneurysm (LVA) is a late complication of a myocardial infarction. It is defined as an area of the ventricular myocardium with a thinner myocardium of the adjacent wall that manifests akinesia or dyskinesia and that affects the entire thickness of the wall. The location of an LVA in up to 80% of cases is the antero-apical wall associated with obstruction of anterior descending artery [1]. Survival to 3 and 5 years is 27% and 12%, respectively, with appropriate surgical treatment survival to 5 years increases to 71% [2].
Less common causes of aneurysms include trauma, hypertrophic or congenital cardiomyopathy, infective endocarditis, inflammatory disease such as Chagas disease or sarcoidosis and idiopathic dilated cardiomyopathy [3].
The principal symptoms are dyspnea, angina, and ventricular arrhythmias. Complications include systemic embolism and rupture of the left ventricular wall [4].
The objective of this study was to present three patients with myocardial infarction who were selected because they developed atypical aneurysms and had a greater survival than the described in the literature.

Material and Methods
Three patients with LVA in atypical locations who attended the Ignacio Chavez National Institute of Cardiology in the period from August 2018 to June 2019 were included in our study. All patients had complete clinical histories and non-invasive imaging studies including transthoracic echocardiography (TTE), cardiac magnetic resonance (CMR) and nuclear cardiology (NC) performed. They also underwent cardiac catheterization.
The study periods and study site were advised to be provided in the Materials and methods section.

Echocardiography
Two and three-dimensional transthoracic echocardiograms were performed on all patients using a Siemens Acuson 2000 machine with a mechanical probe with M-mode, color and tissue Doppler and 2D and 3D capabilities. The patient assumed a lateral decubitus position. Measurements of heart chambers and wall thickness were taken from parasternal long axis images in systole and diastole.
Global and segmental mobility of both ventricles was assessed from parasternal

Cardiac Catheterization
This study was performed in an experimented hemodynamic service by expert cardiologists following previously described guidelines [8] [9].

Results
The mean age of studied patients was 58.33 ± 10.37 years. The locations of the ventricular aneurysms were lateral, inferior and septal, respectively. The patients received optimal medical treatment to control heart failure and were discharged in G. Camacho-Camacho et al. World Journal of Cardiovascular Diseases stable condition without early mortality. The mean follow-up was of 6.33 years (intervals: 2 -9) and during this period the patients were NYHA functional class I/II.

Case 1
This patient was a 51-year-old male with a heart murmur detected at 3 months

Case 3
This   Myocardial perfusion study SPECT that shows a transmural infarction of the apex and apical third of the antero-septal region and anterior wall without ischemia of the residual tissue, mild ischemia of the apical third of the infero-septal region. Intraventricular asynchrony was also observed. CMR, myocardial perfusion, coronary angiotomography and cardiac catheterization. The mean LVEF on admission was 29% ± 0.5%, while during follow-up (mean 6.5 ± 3.9 years) under optimal pharmacological treatment the LVEF improved to 41% ± 3.6% ( Figure 6).

Discussion
Ventricular aneurysms are late complications of myocardial infarctions. Extension of an anterior infarction occurs in 35 to 45% of cases and at lower percentages for infarctions in other locations-10% -15% involving the inferior wall, 7.9% the interventricular septum and only 1% the lateral wall [10]. Ventricular aneurysms of the lateral wall correspond to obstruction of the anterior descending artery and the marginal branch of the circumflex coronary artery, while in cases involving the inferior wall are due to descending artery, right coronary and circumflex artery obstruction [11]. The formation of aneurysms increases mortality due to the complications they precipitate, such as ventricular arrhythmias, embolism and moderate to severe mitral regurgitation secondary to distortion of papillary muscle anatomy. When any of these complications exists revascularization of the affected coronary artery together with resection of the aneurysm and/or mitral valve repair should be performed. However, when surgical risk is high, anticoagulation and reduction of afterload is recommended [5]. A ventricular septal aneurysm is rarely detected in the adult population. Among pediatric patients it is associated with congenital heart disease in 0.3% and secondary to trauma or infection in other cases [12] [13]. There are some reports of patients between the ages of 30 and 50 who developed atypical aneurysms, which initially manifest neurological symptoms such as motor aphasia and unilateral hemiparesis, even before presenting cardiac symptoms such as chest pain and dyspnea in exertion [12], as it happened with the case 1. Septal aneurysms have been associated with eccentric flow that constantly hits the septum because of mitral stenosis [14].
In patients with myocardial infarction it is very important to distinguish between true aneurysms and pseudoaneurysms. LV pseudoaneurysm is a result of rupture of the ventricular free wall but contained by the adherent pericardium,  Cardiac catheterization is an invasive method that still remains essential in the diagnosis and treatment of coronary lesions.
All of our patients have demonstrated improvement in their functional class with pharmacological treatment. The mean LVEF during follow-up was 41%, which indicates a good prognosis for survival in these patients.

Conclusions
The location of ventricular aneurysms varies according to the obstruction site in coronary arteries.
Non-invasive imaging techniques are extremely valuable in the diagnosis and follow-up of patients with ventricular aneurysms in atypical locations.
Surgical intervention is contemplated only for cases of failed medical treatment, hemodynamic instability, refractory heart failure or ventricular tachyarrhythmias.
Survival of these patients depends on the precise diagnosis and optimal treatment.