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Left Ventricular Pseudoaneurysm in a Patient with Dressler's Syndrome

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Left Ventricular Pseudoaneurysm in a Patient with Dressler's Syndrome 98 Heart 1998;80:98–100 CASE REPORT Heart: first published as 10.1136/hrt.80.1.98 on 1 July 1998. Downloaded from Left ventricular pseudoaneurysm in a patient with Dressler’s syndrome after myocardial infarction H Reinecke, T Wichter, M Weyand Abstract should be monitored carefully for several Successful recanalisation of the left ante- weeks, especially by echocardiography. rior descending coronary artery was per- (Heart 1998;80:98–100) formed in a 51 year old man who was Keywords: Dressler’s syndrome; pseudoaneurysm; admitted two weeks after acute anterior myocardial infarction Department of myocardial infarction. Fourteen days Cardiology and later, the patient developed Dressler’s Angiology, Hospital of syndrome with cardiac tamponade, which the Westfälische Perforation or rupture of the left ventricular Wilhelms-University, was immediately punctured. Sternotomy free wall is a dramatic and often fatal Münster, Germany was performed after two weeks because of complication that typically occurs three to five H Reinecke progressive haemodynamic deterioration, days after the onset of acute myocardial infarc- T Wichter and fibrinous masses were removed from tion (AMI). Adhesions of epicardium and peri- cardium, and a parietal thrombus at the region Department of the pericardium. The patient recovered Thoracic and but two weeks later echocardiography of infarct may lead to the formation of a pseu- Cardiovascular showed a perforation of the left ventricu- doaneurysm in which the walls are formed by Surgery, Hospital of lar free wall and formation of a pseudoan- pericardium and organised thrombotic 1 the Westfälische eurysm. Intensive monitoring showed material. Because of a high incidence of spon- Wilhelms-University taneous and frequently fatal ruptures of these M Weyand significant enlargement of the pseudoan- http://heart.bmj.com/ eurysm, which was subsequently resected. pseudoaneurysms, the treatment of choice is surgical resection.1 Correspondence to: This case demonstrates that dangerous In addition to this acute complication, Dr H Reinecke, formation of a pseudoaneurysm can occur Medizinische Klinik und Dressler’s syndrome (also called postmyocar- Poliklinik—Innere Medizin not only during the first days of acute C, Westfälische dial infarction syndrome) can occur two to myocardial infarction but also after weeks 2 Wilhelms-Universität, eight weeks after the onset of AMI. This com- D-48129 Münster, Germany. in patients suVering from non-infectious plication was originally described as occurring pericarditis caused by Dressler’s syn- in 1–4% of all patients with AMI.3 Characteris- Accepted for publication drome. Although the incidence of on September 27, 2021 by guest. Protected copyright. 23 December 1997 tics are systemic signs of inflammation (ma- Dressler’s syndrome is declining, patients laise, fever, leucocytosis) without evidence of infection, together with pericardial and often pleural eVusion. Cardiac tamponade is a rare but dangerous manifestation of the syndrome.2 Although the pathogenesis of Dressler’s syn- drome is not clear, an immunopathological genesis has been considered.2–4 We describe a patient who developed left ventricular pseudoaneurysm four weeks after onset of exudative pericarditis associated with Dressler’s syndrome, who had successful surgi- cal resection. Case report A 51 year old man developed a large anterior myocardial infarction with a peak creatine kinase of 1700 U/l despite thrombolysis. Four- teen days after onset of the infarction he was admitted to our department for coronary angio- graphy because of unstable angina pectoris. Angiography showed mild dyskinesia of the Figure 1 Four weeks after the onset of Dressler’s syndrome (eight weeks after myocardial anterior wall and single vessel disease with a infarction) the pseudoaneurysm was primarily detected. Echocardiographic three chamber proximal occlusion of the left anterior descend- view shows perforation of the left ventricular wall, extracardial space, and floating parts of myocardial tissue at the margins of the perforation (arrow). LA, left atrium; LV,left ing coronary artery. Subsequent recanalisation ventricle; AO, aorta. with angioplasty was successful. Two weeks Pseudoaneurysm in a patient with Dressler’s syndrome after MI 99 Heart: first published as 10.1136/hrt.80.1.98 on 1 July 1998. Downloaded from Figure 2 Six weeks later (14 weeks after myocardial infarction). (A) Three chamber view shows pericardial eVusion, significant enlargement of the perforation, and of the false lumen. (B) Four chamber view shows echo-free edges at the margins of the false lumen (arrows), which was http://heart.bmj.com/ interpreted as progressive detachment of the pasted epicardium and pericardium. (C) Left ventriculography performed preoperatively (right anterior oblique projection) showing the large size of the pseudoaneurysm. LA, left atrium; RA, right atrium; RV,right ventricle; LV,left ventricle; AO, aorta; AN, false lumen of pseudoaneurysm. after recanalisation (four weeks after AMI), the Four weeks after onset of pericarditis (eight patient developed fever and showed signs of weeks after AMI), routine echocardiography cardiac decompensation with tachypnoea, hy- showed a perforation of the anterior left on September 27, 2021 by guest. Protected copyright. potension, and sinus tachycardia. At this time, ventricular wall (fig 1) with small, floating parts echocardiography showed cardiac tamponade of myocardial tissue at the margins of the per- and dyskinesia of the anterior wall. An foration. Colour Doppler showed a flow emergent pericardial puncture was performed; between the left ventricular cavity and the 720 ml of serous liquid were drained from the “false lumen” (not shown). A parietal throm- pericardium and the patient recovered haemo- bus was also observed but dissolved after one dynamically. The drained fluid was sterile and week with anticoagulation using heparin. contained a significant amount of polymorpho- Asymptomatic myocardial re-infarction as a nuclear leucocytes. Over the next two weeks, possible cause for the perforation was excluded 100 ml/day of sterile pericardial e usion was V because of daily electrocardiographic and drained, and the patient had persistent signs of laboratory measurements. Surgery was post- general infection: blood leucocytosis of 20 000 poned because of the recent active pericarditis. leucocytes/µl and continuous fever > 38.5°C. Chest radiography showed mild bilateral pleu- Intensive echocardiographic controls for the ral eVusion. The patient worsened haemody- next six weeks showed mild but progressive namically and echocardiography showed echo- pericardial eVusion, significant enlargement of rich masses surrounding the heart. A the wall perforation and of the false lumen (figs sternotomy was performed during which sig- 2A and B). Additionally, echo-free separations nificant masses of fibrinous detritus were appeared at the margins of the false lumen and removed and three drains inserted for pericar- became larger. This was interpreted as progres- dial lavage. No infectious agent was isolated in sive detachment of the pasted epicardium and several blood samples or the material from the pericardium (fig 2B). A preoperative coronary sternotomy, nevertheless prophylactic anti- angiography showed a good short term result biotic treatment was started. Postoperatively, of angioplasty, and left ventriculography the patient felt well and after two weeks he showed the large size of the pseudoaneurysm showed no more clinical signs of inflammation. (fig 2C). 100 Reinecke, Wichter, Weyand A repeat sternotomy was performed using with possible subsequent formation of extracorporeal circulation and cold cardio- pseudoaneurysm.9 Our patient developed the plegic cardiac arrest (six weeks after diagnosis pseudoaneurysm without receiving any of these of the perforation). The false lumen was freed drugs. Heart: first published as 10.1136/hrt.80.1.98 on 1 July 1998. Downloaded from from its surrounding adhesions and partially The prevalence of Dressler’s syndrome was resected, including the rest of the parietal originally thought to be 1–4% of patients with thrombotic material. The borders of the perfo- AMI.3 Recent studies have shown the inci- rated defect were sewed and armed with a dence to be declining because of successful Dacron patch. The free margins of the false thrombolysis in patients with AMI.10 Although lumen were covered over the closed perforation the incidence has decreased, and formation of and fixed as an additional enforcement. pseudoaneurysm after Dressler’s syndrome has Further postoperative follow up was free from to be considered a rare complication, the high complications, and the patient was discharged rate of spontaneous and often fatal ruptures of to a rehabilitation centre two weeks after pseudoaneurysms should be remembered. Be- surgery. cause prompt diagnosis and surgical treatment are essential, an intensive and prolonged moni- Discussion toring of patients with Dressler’s syndrome In addition to the reports about pseudoaneu- should be performed, particularly with rysms as a typical early complication after echocardiography. AMI, there have been a few reports of pseudoaneurysm formation in patients without coronary heart disease caused by purulent 1 Brown SL, Gropler RJ, Harris KM. Distinguishing left ven- 5 6 7 tricular aneurysm from pseudoaneurysm: a review of the pericarditis (even in a child ), endocarditis, literature. Chest 1997;111:1403–9. and penetrating chest trauma.8 2 Gregoratos G. Pericardial involvement
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