Multimodal Visualization of the Left Ventricular Postinfarction Aneurysms: Current State of the Problem and Own Observation Results
Background. Left ventricular aneurysm (LVA) is a complication occurring in 5–10% of acute myocardial infarction (AMI) patients significantly complicating AMI acute stage course and leading to advanced congestive heart failure (CHF) progress. Non-invasive LVA visualization includes echocardiography, cardiac magnetic resonance imaging (MRI), radio-nuclide ventriculography, and multi-slice computed tomography (MSCT). It can also be detected during heart catheteriza-tion by coronary ventriculography (CVG). Each method has its advantages and drawbacks.
The aim. To analyze multimodal non-invasive LVA visualization methods (echocardiography and MSCT) in order to establish accuracy of these methods compared to CVG regarding the diagnosis of LVA and LVA thrombosis.
Methods. We examined 60 patients after AMI with LVA admitted for surgical revascularization and left ventricular aneurysm resection (LVAR). Control group included 110 patients after AMI prior to revascularization without history of LVA. All the patients underwent CVG, heart MSCT and echocardiography prior to surgery.
Results. Mean patients’ age was 60.9±11.4 years (46 [76.7%] men and 14 [23.3%] women, mean LVEF was 42.7±11.1%. Significant CAD according to coronary angiography (CAG) before surgery was proved in 59 (98.3%) pa-tients, and 1 (1.7%) patient had no significant coronary lesions. The majority of patients had anterior LVA localization after AMI in LAD area (57 [95.0%] patients), 2 (3.3%) patients were diagnosed with inferior LVA after AMI in RCA area, and 1 (1.7%) patient had posterior-lateral LVA in Cx area. There was high correlation between LVEF obtained with echo-cardiography and that obtained with MSCT (r=0.955, p<0.0001), although mean LVEF obtained with echocardiography was significantly higher compared to MSCT results (42.7±11.1% vs. 32.7±9.3%, p<0.0001). Comparison of accuracy of the methods in LVA diagnosis showed that MSCT was the most precise method with significantly higher sensitivity compared to CVG and echocardiography (94.9% vs. 75.0%, p=0.002, and 88.0%, p=0.023, respectively), and MSCT significantly ex-ceeded CVG in all diagnostic method accuracy indices. Echocardiography also significantly exceeded CVG in all diagnostic accuracy indices. Comparison of accuracy of the methods in LVA thrombosis diagnosis showed similar results: echocar-diography was much more precise in terms of sensitivity (79.4% vs. 58.8%, p<0.0001) and the rest of indices. MSCT was much more precise in terms of all indices compared to CVG, and also significantly exceeded echocardiography results in terms of sensitivity (97.1% vs. 79.4%, p<0.0001), positive (PPV) (100.0% vs. 93.1%, p=0.0005) and negative predictive value (NPV) (99.1% vs. 93.9%, p=0.0091), integral “area under curve” index (AUC) (0.99 vs. 0.89, p=0.0001) and odds ratio (OR) (3630 vs. 208, p<0.0001).
Conclusions. High correlation of LVEF according to echocardiography and MSCT results allows to skip CVG as a global LV contractility evaluation method enabling to reduce the procedure time. The lowest accuracy of CVG in the diagnosis of LVA and LVA thrombosis also allows to reduce the duration and volume of the invasive procedure to selective CAG and to reduce radiation exposure for patients and operators in favor of non-invasive and more accurate methods (MSCT and echocardiography). MSCT is the most accurate method for LVA thrombosis diagnosis, but it is completely comparable to echocardiography in LVA diagnosis per se, making echocardiography the method of choice in screening and stratification of patients after AMI regarding myocardial revascularization only or combined surgical revascularization with LVAR due to its rapidness, low cost and absence of patient-related adverse effects.
- Marzlin KM. Ventricular Aneurysm: Diagnosis and Treatment. AACN Adv Crit Care. 2017;28(4):391-394. https://doi.org/10.4037/aacnacc2017306.
- Sattar Y, Alraies MC. Ventricular Aneurysm. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2020 Jan. PubMed PMID: 32310415.
- Leucker TM, Agrawal V, Rahim H, Price J, Jones SR. Idiopathic ‘True’ Left Ventricular Aneurysm. J Cardiol Cases. 2015;12(6):202-204. https://doi.org/10.1016/j.jccase.2015.08.013.
- de Agustin JA, de Diego JJ, Marcos-Alberca P, Rodrigo JL, Almeria C, Mahia P, Luaces M, Garcia-Fernandez MA, Macaya C, de Isla LP. Giant and thrombosed left ventricular aneurysm. World J Cardiol. 2015;7(7):431-433. https://doi.org/10.4330/wjc.v7.i7.431.
- Iqbal M, Denny E, Garg S, Jubber A. Image of the month: Left ventricular aneurysm. Clin Med (Lond). 2017 Feb;17(1):91-92. https://doi.org/10.7861/clinmedicine.17-1-91.
- Pace G, Filippone G, Corrado E, Triolo F, Argano V, Novo S. Echocardiographic Assessment of Ventricular Septal Rupture and Left Ventricular Aneurysm after Inferior and Posterior Myocardial Infarction. J Cardiovasc Echogr. 2018 Jan-Mar;28(1):61-64. https://doi.org/10.4103/jcecho.jcecho_29_17.
- Yesin M, Kalçık M, Alizade E, Taşar O, Özkan M. Multimodality imaging of a left ventricular aneurysm in a patient with normal coronary arteries: Unusual localization. Echocardiography. 2017 Jul;34(7):1110-1111. https://doi.org/10.1111/echo.13557.
- Blackman D, Sprigings DC, Lever N, Bashir Y. Left ventricular pseudoaneurysm. Lancet. 2000 Nov 11;356(9242):1642. https://doi.org/10.1016/s0140-6736(00)03158-5.
- Amrakhov SZ, Vicshipanov AS. Khirurgicheskaya taktika i printsipy vypolneniya operatsiy u bolnykh ishemicheskoy boleznyu serdtsa s postinfarktnoy anevrizmoy levogo zheludochka zadnebazalnoy lokalizatsii [Surgeon tactics and principles in coronary arteries disease patients with postinfarction left ventricle aneurysm of posterior basal localization]. Byulleten’ NTSSSKH im. A.N. Bakuleva RAMN. 2013; 14 (1):26-33. Russian.
- Coene Bales A, Sandelski J, Sareli P, Lang RM. Left ventricular diverticula and aneurysms: congenital and acquired lesions. Echocardiography. 1998;15(1):77-88. https://doi.org/10.1111/j.1540-8175.1998.tb00581.x.
- Tirilomis T, Mahmoud FO, Von der Emde J. Left ventricular false aneurysm. Acta Cardiol. 2000;55(4):269-270. https://doi.org/10.2143/AC.55.4.2005751.
- Ohlow MA. Congenital left ventricular aneurysms and diverticula: an entity in search of an identity. J Geriatr Cardiol. 2017;14(12):750-762. https://doi.org/10.11909/j.issn.1671-5411.2017.12.005.
- Sui Y, Teng S, Qian J, Zhao Z, Zhang Q, Wu Y. Treatment outcomes and therapeutic evaluations of patients with left ventricular aneurysm. J Int Med Res. 2019 Jan;47(1):244-251. https://doi.org/10.1177/0300060518800127.
- Xie M, Zhou H, Cheng TO, Wang J, Wang X, Lu Q, Yang Y, Shi B, Fu Q. Left ventricular apical aneurysm associated with normal coronary arteries following cardiac surgery: Echocardiographic features and differential diagnosis. Int J Cardiol. 2013 Oct 9;168(4):3665-70. https://doi.org/10.1016/j.ijcard.2013.06.001.
- Sipola P, Hedman M, Onatsu J, Turpeinen A, Halinen M, Jäkälä P, Vanninen R. Computed tomography and echocardiography together reveal more high-risk findings than echocardiography alone in the diagnostics of stroke etiology. Cerebrovasc Dis. 2013;35(6):521-530. https://doi.org/10.1159/000350734.
- An Y, Nagashima M, Yamazato S, Hayashi K, Makihara Y, Fukunaga M, Hiroshima K, Ohe M, Goya M. Ventricular tachycardia originating from a heart-shaped idiopathic left ventricular aneurysm diagnosed on a three-dimensional electroanatomical mapping system integrated with CT imaging. Intern Med. 2013;52(12):1347-1352. https://doi.org/10.2169/internalmedicine.52.8742.
- Erol C, Koplay M, Olcay A, Kivrak AS, Ozbek S, Seker M, Paksoy Y. Congenital left ventricular wall abnormalities in adults detected by gated cardiac multidetector computed tomography: clefts, aneurysms, diverticula and terminology problems. Eur J Radiol. 2012 Nov;81(11):3276-3281. https://doi.org/10.1016/j.ejrad.2012.03.025.
- Wei H, Tian C, Schindler TH, Qiu M, Lu M, Shen R, Tian Y, Zhao SH, Zhang X. The impacts of severe perfusion defects, akinetic/dyskinetic segments, and viable myocardium on the accuracy of volumes and LVEF measured by gated (99)mTc-MIBI SPECT and gated (18)F-FDG PET in patients with left ventricular aneurysm: cardiac magnetic resonance imaging as the reference. J Nucl Cardiol. 2014 Dec;21(6):1230-1244. Erratum in: J Nucl Cardiol. 2015 Aug;22(4):785. https://doi.org/10.1007/s12350-015-0120-9.
- Penkalla A, Solowjowa N, Dandel M, Knosalla C. Giant true inferoposterior left ventricular aneurysm presenting with heart failure: insights from multimodality imaging. Eur J Cardiothorac Surg. 2014 Aug;46 (2):333. https://doi.org/10.1093/ejcts/ezt590.
- Luni FK, Moza A, Sheikh M, Coker MF, Chaganti SK, Lewis TJ, Kanjwal Y. Nonobstructive hypertrophic cardiomyopathy with left ventricular aneurysm: the role of cardiac magnetic resonance. Tex Heart Inst J. 2013;40(4):465-467. PubMed PMID: 24082381; PubMed Central PMCID: PMC3783143.
- Reading M. Chest X-ray quiz. A ventricular aneurysm. Aust Crit Care. 1999 Dec;12(4):146, 169. PubMed PMID: 11271029.
- Makaryus AN, Peters MR. Congenital Left Ventricular Diverticulum Diagnosed by 64-Detector CT Imaging. J Invasive Cardiol. 2008 Jul; 20(7):372-73. PubMed PMID: 18599900.
- Gopal A, Pal R, Karlsberg RP, Budoff MJ. Left ventricular pseudoaneurysm by cardiac CT angiography. J Invasive Cardiol. 2008 Jul;20(7):370-371. PubMed PMID: 18599899.
- Schlösser FJ, Mojibian HR, Dardik A, Verhagen HJ, Moll FL, Muhs BE. Simultaneous sizing and preoperative risk stratification for thoracic endovascular aneurysm re-pair: Role of gated computed tomography. J Vasc Surg. 2008 Sep;48(3):561-70. https://doi.org/10.1016/j.jvs.2008.04.055.
- Fedkiv SV. [Studying heart anatomy features and left ventricle morpho-functional state by MSCT-ventriculography]. Promeneva diahnostyka, promeneva terapiia. 2010;2:70-75. Ukrainian.
- Fedkiv SV. [European strategy of coronary arteries disease using non-invasive visualization]. Radiation Diagnostics, Radiation Therapy. 2015;1-2:101-112. Ukrainian.
- Fedkiv SV, Telychkun SS. [Magnetic resonance imaging in the diagnosis of the ischemic myocardial lesions of the left ventricle]. Ukrainian Journal of Cardiology. 2015;3:102-112. Ukrainian.
- Frances CD, Shlipak MG, Grady D. Left ventricular pseudoaneurysm: diagnosis by cine magnetic resonance imaging. Cardiology. 1999;92(3):217-219. https://doi.org/10.1159/000006975.
- Weiss RG. Evolving cardiovascular applications for magnetic resonance imaging. Cleve Clin J Med. 2001 Mar;68(3):238-242. https://doi.org/10.3949/ccjm.68.3.238.
- Sharma A, Kumar S. Overview of left ventricular outpouchings on cardiac magnetic resonance imaging. Cardiovasc Diagn Ther. 2015 Dec;5(6):464-470. https://doi.org/10.3978/j.issn.2223-3652.2015.11.02.
- D’Cruz IA, Hayes M, Killam HA. Echocardiographic Features of Large Posterobasal Left Ventricular Aneurysms. Echocardiography. 1996 Jan;13(1):65-70. https://doi.org/10.1111/j.1540-8175.1996.tb00868.x.
- Ikeda N, Yasu T, Yamada S, Ino T, Saito M. Echocardiographical demonstration of a progressively expanding left ventricular aneurysm preceded by endomyocardial tearing. Jpn Circ J. 2001 Apr;65(4):341-342. https://doi.org/10.1253/jcj.65.341.
- Sivarajan M, Klues HG, Krebs W, Steinert S, Franke A, Janssens U, Hanrath P. Clinical determinations of volumes of normal and aneurysmatic left ventricles by three-dimensional transesophageal echocardiography. Echocardiography. 1998 Oct;15(7):641-650. https://doi.org/10.1111/j.1540-8175.1998.tb00662.x.
- Nikus K, Birnbaum Y, Eskola M, Sclarovsky S, Zhong-Qun Z, Pahlm O. Updated Electrocardiographic Classification of Acute Coronary Syndromes. Curr Cardiol Rev. 2014;10(3):229-236. https://doi.org/10.2174/1573403X10666140514102754.
- Nagueh SF, Smiseth OA, Appleton CP, Byrd BF 3rd, Dokainish H, Edvardsen T, Flachskampf FA, Gillebert TC, Klein AL, Lancellotti P, Marino P, Oh JK, Popescu BA, Waggoner AD. Recommendations for the Evaluation of Left Ventricular Diastolic Function by Echocardiography: An Update from the American Society of Echocardiography and the European Association of Cardiovascular Imaging. J Am Soc Echocardiogr. 2016;29(4):277-314. https://doi.org/10.1016/j.echo.2016.01.011.
- Prasad SB, Holland DJ, Atherton JJ, Whalley G. New Diastology Guidelines: Evolution, Validation and Impact on Clinical Practice. Heart Lung Circ. 2019;28(9):1411-1420. https://doi.org/10.1016/j.hlc.2019.03.013.
- Rudski LG, Lai WW, Afilalo J, Hua L, Handschumacher MD, Chandrasekaran K, Solomon SD, Louie EK, Schiller NB. Guidelines for the Echocardiographic Assessment of the Right Heart in Adults: A Report from the American Society of Echocardiography Endorsed by the European Association of Echocardiography, a registered branch of the European Society of Cardiology, and the Canadian Society of Echocardiography. J Am Soc Echocardiogr. 2010;23(7):685-713. https://doi.org/10.1016/j.echo.2010.05.010.
- Nesukai OH, Danylenko OO. [Role of speckle tracking echocardiography in the diagnosis and treatment of cardiovascular diseases]. Hypertension. 2018;2(58):33-43. Russian. https://doi.org/10.22141/2224-14220.127.116.118.131064.
- Bernard A, Addetia K, Dulgheru R, Caballero L, Sugimoto T, Akhaladze N, et al. 3D echocardiographic reference ranges for normal left ventricular volumes and strain: results from the EACVI NORRE study. Eur Heart J Cardiovasc Imaging. 2017 Apr 1;18(4):475-483. https://doi.org/10.1093/ehjci/jew284.
- Liou K, Negishi K, Ho S, Russell EA, Cranney G, Ooi SY. Detection of Obstructive Coronary Artery Disease Using Peak Systolic Global Longitudinal Strain Derived by Two-Dimensional Speckle-Tracking: A Systematic Review and Meta-Analysis. J Am Soc Echocardiogr. 2016 Aug;29(8):724-735.e4. https://doi.org/10.1016/j.echo.2016.03.002.
- Pastore MC, Mandoli GE, Contorni F, Cavigli L, Focardi M, D’Ascenzi F, Patti G, Mondillo S, Cameli M. Speckle Tracking Echocardiography: Early Predictor of Diagnosis and Prognosis in Coronary Artery Disease. Biomed Res Int. 2021 Feb 2;2021:6685378. https://doi.org/10.1155/2021/6685378.
- Lazoryshynets VV, Kovalenko VM, Potashev SV, Fedkiv SV, Rudenko AV, Vitovskiy RM, Sychov OS, Rudenko SA, Ivaniv YA, Krikunov OA, Mazur OA, Hrubyak LM, Rusnak AO, Osovska NY, Deyak SI, Verich NM, Beshlyaga VM. [Cardiac Chamber Quantification by Echocardiography in Adults: Recommendations from the Association of Cardiovascular Surgeons of Ukraine and Ukrainian Society of Cardiology]. Ukrainian Journal of Cardiovascular Surgery. 2020;4(41):96-117. https://doi.org/10.30702/ujcvs/20.4112/096-18.104.22.16820.
- Lazoryshynets VV, Kovalenko VM, Rudenko AV, Ivaniv YA, Beshlyaga VM, Potashev SV, Trembovetska OM, Salo SV, Gavrylyshyn AY, Rudenko SA, Rusnak AO, Lozoviy OA, Gogayeva OK, Babochkina AR, Soltani SE, Verich NM, Hrubyak LM, Titova NS. [Definition for a Common Stan-dard for 2D Speckle-Tracking Echocardiography (The As-sociation of Cardiovascular Surgeons of Ukraine and the Ukrainian Society of Cardiology Working Group Draft Consensus)]. Cardiology and cardiac surgery: continuous professional development.2019;2:105-129. https://doi.org/10.30702/ccs.201905.02.2DST105129