12 th Annual West Virginia ACC Meeting April 8, 2017

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Leo Farmer
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1 12 th Annual West Virginia ACC Meeting April 8, 2017 Rameez Sayyed, M.D., FACC, FSCAI Associate professor of Medicine Program Director for interventional cardiology Marshall University Joan C. Edwards School of Medicine

2 49 y/o male 2 month history of dry cough Generalized fatigue and shortness of breath. Intermittent history of chest pain. Physical examination reveled tachycardia and distant heart sounds. JVP was also elevated. Elevated BNP and D-Dimer, but normal troponin. EKG showed ST-T depression in leads II, V2-5 and T wave inversion in leads III and AVF.

4 Pericardial Effusion

5 Small Bilateral Pleural Effusions

6 Cardiac Tamponade

7 Basal Inferior LV Aneurysm

12 An emergent pericardiocentesis drained 1L of serosanguinous fluid. Left heart catheterization revealed chronic changes in his coronary vasculature with 50% stenosis at ostium of RCA and a very large basal inferior left ventricular aneurysm. Patient was transferred to tertiary care center for LV aneurysm resection and revascularization procedure. He is doing well after surgery.

13 An LVA is most commonly the result of MI, usually involving the anterior wall. Other causes of LVA include: Hypertrophic cardiomyopathy Chagas disease both of which can lead to the formation of an apical aneurysm. The aneurysm may be asymptomatic or present as heart failure, sustained ventricular tachyarrhythmias, or arterial embolism. A pseudoaneurysm, or false aneurysm, develops after an acute MI that is complicated by a ventricular free wall rupture that is contained by localized pericardial adhesions.

14 Incidence It was previously estimated that LVA develops in up to 30 to 35 percent of patients with Q wave MI. However, the incidence of this complication is decreasing, and currently is about 8 to 15 percent in such patient. This change is related to the introduction of major improvements in the management of patients with acute MI. There are a number of serious complications that can occur as a consequence of LVA: Heart failure ventricular arrhythmias Thromboembolism Ventricular rupture

15 Medical therapy: Small to moderate size asymptomatic aneurysms can be safely treated medically with an anticipated five-year survival of up to 90 percent. Therapy consists of afterload reduction for LV enlargement, usually with an angiotensin converting enzyme inhibitor, antiischemic medications for angina, and anticoagulation if there is significant LV dysfunction or evidence of thrombus within the aneurysm or LV.

16 The optimal approach to the patient with a large, asymptomatic LVA remains a clinical dilemma. Concomitant repair of the aneurysm has been advocated when coronary artery bypass surgery (CABG) or valve surgery is performed. In the absence of such indications for surgery, these patients should otherwise be treated with the same regimen as those with a small LVA; they should also be followed closely for progressive left ventricular dilation. Oral anticoagulation The identification of a mural thrombus in patients with a post-infarction LVA warrants consideration of oral anticoagulation to prevent embolization.

17 The majority of the operations for repair of an LVA are performed via a median sternotomy incision using cardiopulmonary bypass. In unusual circumstances, the operation can be performed via a left thoracotomy, particularly for posterior aneurysms. An alternative approach to inferior-basal aneurysms is via the left atrium.

18 Untreated pseudoaneurysms have a 30 to 45 percent risk of rupture and, with medical therapy, a mortality of almost 50 percent. Thus, surgery is the preferred therapeutic option. With current techniques, the perioperative mortality is less than 10 percent; the risk is greater among patients with severe mitral regurgitation requiring concomitant mitral valve replacement.

Atherosclerotic Heart Disease: Coronary Vessels, EKG Localization of STEMI and Complications/Derivatives for USMLE Step One

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