The Role of Multimodality Imaging in a Case of Traumatic Cardiac Pseudoaneurysm

Abstract: After a 40-foot fall from a balcony, a healthy 21-year-old sustained multiple injuries, including left ventricular pseudoaneurysm. This case demonstrates the critical necessity of the combination of a high index of suspicion and multimodality imaging for diagnosis and prompt intervention. 

J INVASIVE CARDIOL 2016;28(8):E71-E72

Key words: blunt-force trauma, left ventricular pseudoaneurysm

Case Presentation

A healthy 21-year-old woman sustained a 40-foot fall from a collapsed balcony. She had multiple intraabdominal injuries, fractures, bilateral pneumothoraces, subarachnoid hemorrhage, and suspected diffuse axonal injury. Initial electrocardiogram was notable for diffuse ST-segment elevation and transthoracic echocardiogram (TTE) showed trace mitral regurgitation (MR) and a trivial pericardial effusion, attributed to traumatic pericarditis. Her course was complicated by sympathetic storming, managed with sedation and clonidine.   

On hospital day 5, the patient developed hypotension requiring vasopressors. A repeat TTE revealed a moderate pericardial effusion and increased MR with an unusual eccentric jet. Subsequent transesophageal echocardiogram demonstrated a possible pseudoaneurysm at the base of the posterior leaflet of the mitral valve with new moderate MR (Figure 1). She underwent left and right heart catheterization with hemodynamic data consistent with pericardial tamponade. Left ventricular angiogram showed a possible pseudoaneurysm at the base of the anterolateral wall (Figure 2; Video 1). Pericardiocentesis was performed, revealing 300 mL of dark sanguineous fluid and resulting in hemodynamic improvement. Subsequent cardiac computed tomography angiogram demonstrated 13 mm pseudoaneurysm of the posterolateral wall just below the mitral annulus, with a 5 mm neck (Figure 3). 

Due to high clinical suspicion for a ventricular pseudoaneurysm related to her initial blunt-force trauma, the patient was transferred to the neighboring hospital for cardiac surgery. The intraoperative findings included posterior atrioventricular groove disruption with tearing of the posterior mitral leaflet from the annulus and a 5 mm perforation of P1 at the annulus transecting the posterior left ventricular wall. She underwent repair of a traumatic atrioventricular groove disruption and mitral valve replacement. Postoperatively, the patient had significant clinical improvement. She was discharged several weeks later with remarkable neurologic recovery and was able to fly home overseas.

Left ventricular pseudoaneurysm is a potentially lethal consequence of blunt-force trauma. This case demonstrates the critical necessity of the combination of a high index of suspicion and multimodality imaging for diagnosis and prompt intervention.

From the Division of Interventional Cardiology, Department of Cardiology, Highland Hospital of Alameda Health System, Oakland, California.

Disclosure: The authors have completed and returned the ICMJE Form for Disclosure of Potential Conflicts of Interest. The authors report no conflicts of interest regarding the content herein.

Manuscript submitted April 15, 2016 and accepted April 25, 2016.

Address for correspondence: Dr Brittany N. Mcunu, Highland Hospital, Department of Cardiology, 1411 East 31st Street, Oakland, CA 94602. Email: bmcunu@bison.howard.edu