Clinical History
A 71-year-old woman presented with thoracic pain, asthenia, moderate fever (38 °C), and diffuse bone and articular pain. Laboratory test results showed an increase in the serum level of cardiac
enzymes (Troponin I was 0.8 ng/mL, CPK MB was 12 ng/mL, myoglobin was 90 ng/mL).
Imaging Findings
A 71-year-old woman presented with thoracic pain, asthenia, moderate fever (38 °C), and diffuse bone and articular pain. Laboratory test results showed an increase in the serum level of cardiac
enzymes (Troponin I was 0.8 ng/mL, CPK MB was 12 ng/mL, myoglobin was 90 ng/mL). Electrocardiography was done, which revealed the presence of a left anterior-inferior myocardial infarction, due to
ventricular fibrillation; coronary angiography showed a leading right anterior coronary circulation with an obstruction near the left ventricular apex and moderate pericardic effusion.The patient was
affected by rheumatoid arthrtitis and presented joint deformities and was in treatment with prednisone. Laboratory test values showed the presence of hypergammaglobulinemia and an elevation of
C-reactive protein (18 mg/L) and VES (60). Three months later, the patient presented to our hospital with a dry cough, dyspnea and fatigability on exertion. A multislice contrast-enhanced CT of the
thorax showed the presence of a left apical ventricular aneurysm (measuring 45 mm) containing thrombotic material, diffuse and bilateral bronchopneumonia and moderate pleural and pericardial
effusion. Echocardiography showed ventricular dysfunction and revealed the following: akinesia of the basal and apical left ventricular walls, moderate mitral regurgitation and moderately severe
tricuspid rigurgitation. The patient presented also an enlarged left atrial cavity and aortic sclerosis.
Discussion
Left ventricular (LV) aneurysms are a direct consequence of a myocardial infarction. In fact after extensive infarction, the affected myocardium may become thin and fibrotic, resulting in an outward
bulging of the ventricular wall during systole. An LV aneurysms may be detected after 20%–40% of all infarctions and are most commonly found in the septal, apical and lateral regions. LV
aneurysm occurs more frequently in females and in patients without previous angina and could be completely asymptomatic, but it may lead to left ventricular remodeling with global and regional LV
dysfunction, ventricular arrhythmias, or thromboembolic complications. Rheumatoid arthritis is an important risk factor for cardiovascular disease (the commonest cardiac complication of rheumatoid
disease is pericarditis, followed by non-specific endocarditis and myocarditis, arteritis of the medium and small intramyocardial arteries and valve disease). Recent studies suggest similarities
between the inflammatory pathogenic mechanisms in rheumatoid arthritis and atherosclerosis, and an increased prevalence of ischemic heart disease in rheumatoid arthritis. Cardiovascular mortality
accounts for 40%–50% of all deaths in rheumatoid arthritis. Left ventricular mural thrombus may be detected in 30%–40% of anteroapical infarctions. Mural thrombi are almost invariably
associated with an underlying wall motion abnormality, form early in the course of infarction, and increase the risk for systemic embolization. A ventricular aneurysm can be readily detected by CT,
although this procedure is not considered the gold standard. A contrast-enhanced CT procedure is necessary to detect localized dilatation of the myocardium associated with wall-thinning and mural
thrombus formation. Thrombi and calcifications are easily detectable. The normal contraction of the healthy myocardium may cause blurring, for this reason the wall appears thicker than it actually
is. An infarcted segment generally appears more sharply defined because of its akinesis. However echocardiography, ventricular angiography and cine-MRI technique, which allow the study of both
cardiac anatomy and function, represent the best choice of tecniques for the evaluation of LV aneurysmal function after myocardial infarction.
Differential Diagnosis List
Left ventricular aneurysm.
Final Diagnosis
Left ventricular aneurysm.