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CASE REPORT

CLINICAL CASE

Multimodality Imaging ofRight Ventricular PseudoaneurysmCaused by Blunt Chest Trauma

Kianoush Ansari-Gilani, MD,a Ellen L. Sabik, MD,b Basar Sareyyupoglu, MD,c Robert C. Gilkeson, MDd

ABSTRACT

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Right ventricular pseudoaneurysm is a rare but fatal complication of blunt chest trauma. Different imaging modalities

including transthoracic echocardiogram, gated-CT angiography and cardiac MR can provide useful anatomic and

functional information that can make the diagnosis and guide management. Surgical treatment is needed to avoid fatal

outcome. (Level of Difficulty: Beginner.) (J Am Coll Cardiol Case Rep 2019;1:287–90) © 2019 The Authors. Published by

Elsevier on behalf of the American College of Cardiology Foundation. This is an open access article under the CC BY-NC-ND

license (http://creativecommons.org/licenses/by-nc-nd/4.0/).

A 66-year-old woman who was an unrestraineddriver in a low-speed collision with airbagdeployment was admitted to the emergency

department after full trauma activation. The vitalsigns were stable at the time of presentation.

PAST MEDICAL HISTORY

The patient had history of depression, but otherwisepast medical history was unremarkable for anypertinent disease.

EARNING OBJECTIVES

To understand the imaging findings in rightventricular pseudoaneurysm.To review the causes of ventricularpseudoaneurysm.

N 2666-0849

m the aRadiology Department, University Hospitals Cleveland Medical C

iversity Hospitals Cleveland Medical Center, Cleveland, Ohio; cDepartm

rida; and the dDepartment of Radiology, University Hospitals Cleveland

orted that they have no relationships relevant to the contents of this pap

nuscript received May 28, 2019; revised manuscript received August 6, 2

DIFFERENTIAL DIAGNOSIS

Owing to chest pain and scattered bilateral rib frac-tures, the possibility of aortic dissection and aorticinjury was raised.

INVESTIGATIONS

Electrocardiography was unremarkable. The patientunderwent gated computed tomography (CT) angi-ography of the chest before and after injection ofintravenous contrast to assess for possible aorticinjury.

Noncontrast CT showed a small 10 � 9 mm out-pouching likely arising from the right ventricularapex (Figure 1A), which demonstrated increasedenhancement on the arterial phase of the image(Figure 1B), raising concern for pseudoaneurysm. Asmall amount of pericardial effusion was alsopresent.

https://doi.org/10.1016/j.jaccas.2019.08.006

enter, Cleveland, Ohio; bDepartment of Cardiology,

ent of Cardiac Surgery, Mayo Clinic, Jacksonville,

Medical Center, Cleveland, Ohio. The authors have

er to disclose.

019, accepted August 9, 2019.

FIGUR

(A) No

(arrow

ABBR EV I A T I ON S

AND ACRONYMS

CT = computed tomography

CMR = cardiac magnetic

resonance

LGE = late gadolinium

enhancement

Ansari-Gilani et al. J A C C : C A S E R E P O R T S , V O L . 1 , N O . 3 , 2 0 1 9

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Cardiac magnetic resonance (CMR) wasperformed to confirm the presence of pseu-doaneurysm. Steady-state free precessionimaging again showed small outpouching atthe level of right ventricular apex (Figure 2A).Post-contrast first-pass perfusion CMR im-ages (Video 1) showed increased enhance-ment in the outpouching after contrast

injection with a small amount of associated muralthrombus confirming the presence of a pseudo-aneurysm communicating with the right ventricularcavity. The patient remained stable, and a next-dayfollow-up transthoracic echocardiography was per-formed to assess the myocardial function andpossible interval worsening of pericardial effusion.Transthoracic echocardiography showed an increasein pericardial effusion and signs of pericardial tam-ponade, including absence of respiratory variabilityin the inferior vena cava blood flow (Figure 3A), aswell as significant mitral valve and tricuspid valveinflow variability with respiration (Figures 3B and 3C),raising concern for cardiac tamponade.

MANAGEMENT

The patient was transferred to the operating room.Intraoperative transesophageal echocardiography

E 1 Pseudoaneurysm Arising From the Right Ventricular Apex

n–contrast-gated computed tomography of the chest shows a fo

). (B) This shows increased arterial enhancement in the arterial p

confirmed the presence of cardiac tamponade withright ventricular collapse during diastole. A rightapical pseudoaneurysm (Figure 4A) covered withpericardium and a small amount of mural thrombuswas detected and resected using primary suturetechnique. A moderate amount of pericardial effusionwas also seen and removed.

DISCUSSION

Blunt chest trauma can lead to various types of car-diac complications such as cardiac contusion, cardiacrupture, or formation of pseudoaneurysm (1). It mayresult in ventricular arrhythmias, cardiac failure, orcardiac tamponade (1). The exact incidence of cardiaccontusion is not known but has been reported to be ashigh as 15% to 24% when using specific cardiacmarkers such as troponin I or T (1). Ventricularpseudoaneurysm, which is a contained rupture of theventricular wall (2) and covered by pericardium, clot,or adhesion (3), is a very uncommon complication ofblunt chest trauma (4). Pseudoaneurysms usuallyoccur on the left side, and descriptions of right ven-tricular pseudoaneurysms are limited to rare casereports (5). Pseudoaneurysm is connected tothe ventricle by a small neck (2). This is in contrastto a true ventricular aneurysm, which contains

cal area of soft tissue density abutting the right ventricular apex

hase of gated computed tomography angiography (arrow).

FIGURE 2 Pseudoaneurysm Arising From the Right

Ventricular Apex

Steady-state free precession image of the heart at the same

level again shows focal iso-intense outpouching from the right

ventricular apex (arrow). See Video 1.

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myocardium and has a wider neck at its junction withthe ventricle. The most common cause of ventricularpseudoaneurysm is myocardial infarction (4). Lesscommon causes are cardiac surgery, endocarditis, ormyocardial biopsy (2).

In addition to electrocardiography, which shouldbe done in all patients with blunt trauma to the chest,specific cardiac markers such as troponin I or T shouldbe checked in patients with blunt chest trauma (1).Further assessment can be done with transthoracic

FIGURE 3 Findings Concerning for Cardiac Tamponade on Transthor

(A) Lack of normal respiratory variability (arrows) of the dilated inferior

valve shows significant inflow variability with respiration.

echocardiography or transesophageal echocardio-gram, mainly to assess the cardiac function. CTangiography of the chest can be obtained for betterassessment of cardiovascular anatomy and, if needed,surgical planning (3). CMR can provide both func-tional and anatomic information (3).

Without treatment, the risk of rupture of pseu-doaneurysm is high (up to 40% at 1 year) (6).Therefore, surgical treatment is the standard man-agement, but percutaneous closure has beendescribed in patients at higher risk for surgicalintervention to repair the left (6,7) or right (2) ven-tricular pseudoaneurysm.

FOLLOW-UP

Post-operative CT demonstrated the suture materialat the level of right ventricular apex (Figure 4B). Afterthe surgery, the patient recovered well, with an un-eventful course in the post-operative period andduring the follow-ups.

CONCLUSIONS

Right ventricular pseudoaneurysm is a rare entity,especially after blunt chest trauma. A multimodalimaging approach can be of value in making a timelydiagnosis and treatment to avoid a fatal outcome.

ADDRESS FOR CORRESPONDENCE: Dr. KianoushAnsari-Gilani, University Hospitals Cleveland MedicalCenter, Radiology Department, 11100 Euclid Avenue,Cleveland, Ohio 44106. E-mail: kianoush.ansarigilani@uhhospitals.org.

acic Echocardiography

vena cava. Tissue Doppler recording at the level of (B) the mitral valve and (C) the tricuspid

FIGURE 4 Intraoperative and Postoperative Findings

(A) Intraoperative image shows the right apical pseudoaneurysm (thin arrows) with small amount of mural clot (thick arrow). (B)

Post-operative computed tomography shows post-surgical changes with suture material at the site of resection (arrow).

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RE F E RENCE S

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3. Hulten EA, Blankstein R. Pseudoaneurysms ofthe heart. Circulation 2012;125:1920–5.

4. Bortnick AE, Gordon E, Gutsche J, et al.Percutaneous closure of a left ventricularpseudoaneurysm after Sapien XT transapical

transcatheter aortic valve replacement. J Am CollCardiol Intv 2012;5:e37–8.

5. Frances C, Romero A, Grady D. Left ventricularpseudoaneurysm. J Am Coll Cardiol 1998;32:557–61.

6. Dudiy Y, Jelnin V, Einhorn BN, Kronzon I,Cohen HA, Ruiz CE. Percutaneous closure of leftventricular pseudoaneurysm. Circ CardiovascInterv 2011;4:322–6.

7. Kumar PV, Alli O, Bjarnason H, Hagler DJ,Sundt TM, Rihal CS. Percutaneous therapeuticapproaches to closure of cardiac pseudoaneur-

ysms. Catheter Cardiovasc Interv 2012;80:687–99.

KEY WORDS cardiac magnetic resonance,computed tomography, echocardiography,right ventricle

APPENDIX For a supplementalvideo, please see the online version ofthis paper.