Loss of myocardial integrity is the main cause
of cardiac rupture. Free intrapericardial rupture
usually results in cardiac tamponade and death. If a
cardiac rupture is not containing whole cardiac layers,
pseudoaneurysm formation occurs.[
2] Noninvasive
tests such as two-dimensional echocardiography and,
more recently, three-dimensional echocardiography
may be useful for detecting Doppler activity, or the
same can be accomplished by echocardiographic
contrast. Transesophageal echocardiography could
be more beneficial for the evaluation of posterior
cardiac segments due to its increased sensitivity
compared to TTE. Cardiac MRI and CT can be
performed to assess the structural relationships of the
cardiac aneurysms or pseudoaneurysms detected in
the echocardiography.[
2,
4]
The majority of ventricular aneurysms occur in
the left ventricle.[4] In addition, RV aneurysms are
more frequently located in the RV outflow tract due
to prior congenital heart operations.[4,7] While some
of the RV aneurysms are clinically diagnosed, some
of them are diagnosed postmortem, and most of
these are pediatric cases.[8-11] While transmyocardial
infarcts, trauma, congenital, and cardiomyopathies
are among the causes, some may be idiopathic.[12]
Iatrogenic cases have also been reported.[13] A fatal RV aneurysm case was reported in a patient who
underwent transcutaneous radiofrequency ablation for
Wolff-Parkinson-White syndrome.[13] In addition,
cases of RV aneurysm developing after postinfarct
ventricular septal rupture have also been reported.[14-16]
Cardiac pseudoaneurysms are treated with Amplatzer
septal occluder devices and introduced under
fluoroscopic and angiographic guidance.[4]
Diagnosis of constrictive pericarditis and its
differentiation from restrictive cardiomyopathy
is important but usually difficult. Transthoracic
echocardiography is the initial and sometimes the
only affordable test for the diagnosis of this condition.
As per Hancock,[17] septal bounce, ventricular septal
shift with respiration, and biatrial enlargement are the
three basic signs of TTE in constrictive pericarditis.
In our case, the ejection fraction of 45% was detected
on TTE. The pericardium was fibrotic, thickened
(more than 2 mm), and ventricular septal diastolic
shudder and respiration-related shift were present in
the interventricular septum. Respiratory change in
the mitral valve E/A was more than 25%. Significant
respiratory variation in mitral and tricuspid inflow
velocities represents ventricular interdependence and is
an important pathophysiologic feature in constrictive
pericarditis.[18]
Right ventricular aneurysms may be isolated
or may be accompanied by some congenital
anomalies. A case of a double-chambered left
ventricle-associated RV aneurysm and another case
with hypertrophic cardiomyopathy associated with RV aneurysm have been reported.[19,20] As with left
ventricular aneurysms, the most common cause of
an RV aneurysm is myocardial infarction. Aneurysm
development time after myocardial infarction may
take years, or it may develop within the first week.
An RV aneurysm that developed on the sixth day
postinfarction is available in the literature.[21] The
most sensational study of RV aneurysms was done
by Antonelli Incalzi et al.[22] In their study, they
found the rate of aneurysm development in the
right ventricle after acute myocardial infarction
to be 8.8%. This rate represents a significant
public health problem. Nonetheless, the incidence
of aneurysms is lower in patients followed up after
acute myocardial infarction in the clinic. Due
to blunt traumas and aortic dissections, ruptures
in the heart cavities and pseudoaneurysms can
develop.[23] The symptoms of patients with an
RV aneurysm are nonspecific and have a wide
range. The most common symptoms are fatigue,
shortness of breath, collapse, and palpitation.[24,25]
Along with these, hypotension and hypotensive
attacks may be the first signs.[26] It may manifest as
syncope attacks due to malignant arrhythmias.[27]
The most severe symptom in our patient was fatigue.
Transthoracic echocardiography, transesophageal
echocardiography, CT, CTA, MRI, MRA, and
direct ventriculography are used in diagnosis.[1,28]
In our case, TTE and CTA were utilized. Right
ventricular aneurysms that cause ventricular
dysrhythmias, heart failure, and pulmonary
embolism are indicated for surgery.[6] In the treatment
of pseudoaneurysms, aneurysmectomy or device
closure can be performed.[23] Pseudoaneurysms
requiring additional surgical procedures can be easily
closed with open-heart surgery. In our patient, the
ejection fraction was decreased due to constrictive
pericarditis, and therefore, pseudoaneurysm repair
was performed on a beating heart together with
surgical pericardiectomy. Cardiac complications of
injuries, such as blunt traumas and falling from
heights, may not be noticed in the early period
and manifest in the long term. Therefore, careful
anamnesis of patients can provide some clues to the
physicians. Rare diseases should also be kept in mind
in young patients describing cardiac symptoms.
In conclusion, a detailed medical history and
physical examination are crucial in cases with an
atypical presentation and should not be overlooked.
Patient Consent for Publication: A written informed
consent was obtained from the patient.
Data Sharing Statement: The data that support the
findings of this study are available from the corresponding
author upon reasonable request.
Author Contributions: Design, writing the article and,
analysis: F.A.; Literature review and references: V.P.
Conflict of Interest: The authors declared no conflicts
of interest with respect to the authorship and/or publication
of this article.
Funding: The authors received no financial support for
the research and/or authorship of this article.
){kind=link}
){kind=link}
){kind=link}
){kind=link}