Double bubble trouble: a case of sub-epicardial aneurysms.

Here we validate a case of sub-epicardial aneurysms, the precursor for rupture that leads to pseudo-aneurysm (PSA) in a patient with associated coronary artery disease. Sub-epicardial aneurysms are rare and can lead to cardiac tamponade and death. We discuss a rare case of a 42-year-old female with two large sub-epicardial aneurysms and coronary artery disease initially diagnosed as true aneurysm, highlighting the importance of surveillance and the challenges of using echocardiography to diagnose and manage these aneurysms effectively. These PSA are difficult to be differentiated form a true aneurysm with transthoracic echocardiography. Echocardiographic criteria, such as a neck-to-sac diameter ratio of less than 0.5 and a reduction in wall thickness near the aneurysmal neck by more than 50%, were considered valuable in differentiating these aneurysms. Now simultaneous bi-plane and real-time three-dimensional imaging features of trans-esophageal echo will aid echo cardiologists in better identifying the characteristics of the outpouching, to further aid in differentiating pseudo from true aneurysms and even recognize the stage of the sub-epicardial aneurysms. Subjecting the patient to a surgery also depends on the time of occurrence of the myocardial infarction. It is highly advocated that an urgent procedure should be conducted for left ventricle (LV) PSA found within the first 3 months after an infarction, since the onset of rupture is unforeseeable. Although an accurate separation between false and true aneurysms is foremost critical for appropriate management, this differentiation is often challenging clinically and radiologically even with reasonable experience.