Pseudoaneurysms are a serious complication of myocardial infarction but can be asymptomatic and only detected by chance in patients with previous subclinical events.

The images presented are of a 62-year-old man, a smoker, with no history of heart disease, admitted to our hospital for community-acquired pneumonia. The chest X-ray on admission showed cardiomegaly and the electrocardiogram showed Q waves in the inferior leads. Transthoracic echocardiography revealed mild left chamber dilatation and severe left ventricular systolic dysfunction, with an aneurysmal sac, 8cm in diameter, involving the basal portion of the posterior, inferior and lateral walls and containing a thrombus (Figures 1 and 2). Since unequivocal differential diagnosis between aneurysm and pseudoaneurysm was not possible with this technique, magnetic resonance imaging was performed, which revealed an old extensive inferior infarction, extending to the adjacent portion of the right ventricle, with inferior myocardial wall rupture. A diagnosis was thus established of pseudoaneurysm in the inferior and posterior walls, containing an organized thrombus (Figures 3 and 4). Cardiac catheterization showed single-vessel disease with chronic occlusion of the mid segment of the right coronary artery. Surgical repair was proposed but the patient refused. He remained clinically stable in NYHA class II for 10 months after discharge, but was then lost to follow-up.

Figure 1.

Transthoracic echocardiogram in apical two-chamber view, showing a large aneurysmal sac in the basal and mid segments of the inferior wall containing a thrombus. Myocardial rupture cannot be confirmed.

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Figure 2.

Transthoracic echocardiogram, short-axis view of the left ventricle, showing a large aneurysmal sac in posteroinferior location.

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Figure 3.

Cardiac magnetic resonance, cine gradient echo image in two-chamber view, showing a large aneurysmal sac in the basal and mid segments of the inferior wall. The mitral valve does not appear to be compromised.

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Figure 4.

Delayed enhancement cardiac magnetic resonance images, in short-axis view from the base to the apex and two-chamber view (right bottom corner), showing transmural infarction of the inferior basal and mid segments. The basal inferior segment of the left ventricular wall consists of a giant thrombus (*), infarcted myocardium (**) and pericardium (arrow), confirming a pseudoaneurysm.

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This case illustrates the value of complementary imaging techniques for correct diagnosis of a complication of an extensive asymptomatic infarction.