Hashimoto Katsuya, Yamamoto Hiroyuki, Harada Atsushi, Yamada Hiroyuki, Ikeda Yoshihiko, Hashimoto Toru
Department of Cardiovascular Medicine, Narita-Tomisato Tokushukai Hospital, Chiba, Japan.
Department of Cardiology, Tokyo Medical University Hospital, Tokyo, Japan.
Heliyon. 2024 May 31;10(11):e32197. doi: 10.1016/j.heliyon.2024.e32197. eCollection 2024 Jun 15.
Myocardial infarction-related left ventricular pseudoaneurysm (LVP), covered by the adjacent pericardial or scar tissue, is a fatal sequela of left ventricular rupture. Whereas hypertrophic cardiomyopathy (HCM) may cause left ventricular true aneurysm. Differentiating LVP from left ventricular true aneurysm is crucial because their natural histories and treatment strategies are distinct. However, the incidence and management of HCM-related LVP remain unknown.
An 88-year-old man was admitted to our hospital with sudden-onset chest pain. Upon initial examination, vital signs were stable, and a grade 4/6 systolic murmur was noted. An electrocardiogram revealed atrial fibrillation and poor R-wave progression without ST-T changes or negative T-waves. An echocardiography showed mild left ventricular hypertrophy, mid-ventricular obstruction with a significant intraventricular pressure gradient, left ventricular outflow tract obstruction, and a small left ventricular apical outpouching. Cardiac computed tomography angiography (CCTA) assisted in the diagnosis of LVP, and an accompanying pericardial effusion suggested impending cardiac rupture. Because the patient initially refused our proposed urgent surgery, medication was initiated with continuous hemodynamic monitoring in the intensive care unit; however, the patient's condition did not improve. During a semi-urgent surgical repair of the aneurysmal wall, LVP was observed and confirmed by pathology. Myocardial tissue adjacent to the pseudoaneurysm was consistent with that of HCM. Subsequently, a final diagnosis of HCM-related LVP was made. The postoperative course was notable for transient profound hypotension. Thereafter, the patient died of non-occlusive mesenteric ischemia on day 6.
To our knowledge, this is the first reported case of HCM-related LVP mimicking impending cardiac rupture. Our case highlights the importance of considering HCM-related LVP in patients with left ventricular outpouching and CCTA in the LVP diagnosis. In further research, data on the appropriate management of HCM-related LVP should be accumulated.
心肌梗死相关的左心室假性动脉瘤（LVP）由相邻的心包或瘢痕组织覆盖，是左心室破裂的致命后遗症。而肥厚型心肌病（HCM）可能导致左心室真性动脉瘤。区分LVP与左心室真性动脉瘤至关重要，因为它们的自然病史和治疗策略不同。然而，HCM相关LVP的发病率和管理仍不清楚。
一名88岁男性因突发胸痛入院。初诊时，生命体征稳定，可闻及4/6级收缩期杂音。心电图显示心房颤动，R波进展不良，无ST-T改变或T波倒置。超声心动图显示轻度左心室肥厚、心室中部梗阻伴明显的室内压力梯度、左心室流出道梗阻以及左心室心尖部小的膨出。心脏计算机断层扫描血管造影（CCTA）辅助诊断为LVP，同时伴有心包积液提示即将发生心脏破裂。由于患者最初拒绝我们建议的紧急手术，遂在重症监护病房开始药物治疗并持续进行血流动力学监测；然而，患者病情并未改善。在对动脉瘤壁进行半紧急手术修复期间，观察到LVP并经病理证实。假性动脉瘤附近的心肌组织与HCM相符。随后，最终诊断为HCM相关LVP。术后过程以短暂的严重低血压为特征。此后，患者在第6天死于非闭塞性肠系膜缺血。
据我们所知，这是首例报道的HCM相关LVP模拟即将发生心脏破裂的病例。我们的病例强调了在左心室膨出患者中考虑HCM相关LVP以及CCTA在LVP诊断中的重要性。在进一步的研究中，应积累有关HCM相关LVP适当管理的数据。
