Discussion
Conventional treatment of thrombosed LV aneurysm including antithrombotic treatment to reduced the incidence of systemic embolism and mortality[2]. While IDH is a very rare presentation of cardiac rupture, the antithrombotic treatment may cause deadly tamponade. Thus, Early identification and prompt tre­atment is crucial in management for both diseases.
Conventional echocardiography, which is sensitive and specific in the diagnosis of thrombosed LV aneurysm. In general, the endocardial flap and the communication of intracavitary helps distinguish the IDH from the thrombosed LV aneurysm. However, in this case, the shape and the high-activity of the thrombosed LV aneurysm was similar to the cavity caused by IDH. This condition could caused much difficulty for us, and making a definitive judgment was thereby challenging.
Contrast echocardiogram is better than plain echocardiogram in identifying thrombosed LV aneurysms and increases the sensitivity and specificity for the diagnosis of mural thrombi. CMR is the most sensitive and specific study for identifying and assessing thrombosed LV aneurysm preoperatively. To confirm the diagnosis, the contrast echocardiogram and CMR were performed. What were the findings in our patient? There were no ultrasound contrast agents entering into the small chamber (Figure1E). Similarly, magnetic resonance first pass perfusion imaging revealed an abnormal signal intensity area in the apex, which was not enhanced (Figure1H). Therefore, we preliminarily concluded that the patient suffered from a thrombosed LV aneurysm rather than an IDH.
Similar case like this has not been reported in previous studies. However, the indication for aneurysmectomy is certain because previous studies have showed that aneurysmectomy might improve the outcome[4,5]. Therefore, we proposed a surgery treatment strategy. After sugery, our patient did not experience any new impairment of his functional status, neither with complex arrhythmias nor with thrombotic events.
In conclusion, it is sometimes difficult to distinguish a thrombosed LV aneurysm from IDH by conventional echocardiography if the thrombus shape changes. A definitive diagnosis involves multimodal imaging.