Unmasking a contained rupture of the left ventricle with CMR

Description of Clinical Presentation: A 65-year-old male, with a history of coronary artery bypass grafting (CABG) in 2018 and obstructive pulmonary disease, was referred to cardiology for preoperative assessment before surgical removal of a cranial meningioma. The patient presented with dyspnea and hadn’t been to a follow-up visit since his CABG. A transthoracic echo (TTE) performed during his initial workup revealed a large apical thrombus (figure 1, panel A) and severe left ventricular dysfunction. A review of a non-contrast thorax computed tomography (CT) scan (figure 1, panel B) from 2018, originally performed for a parapharyngeal abscess in another hospital, also showed the thrombus, indicating its long-standing presence. Despite this, the patient had not been on oral anticoagulation due to a lack of follow-up. Given the current mass and for preoperative evaluation of coronary perfusion defects a cardiovascular magnetic resonance (CMR) scan with adenosine stress was performed.

Diagnostic Techniques and Their Most Important Findings: CMR was performed on a Siemens Sola 1.5 Tesla scanner using an adenosine stress protocol with early gadolinium enhancement (EGE) imaging to characterize the apical mass. Cine images showed severe left ventricular dysfunction with dyskinesia of the apical segments. Adenosine stress imaging showed no inducible perfusion defects. The EGE images (figure 2) confirmed the presence of a thrombus. The late gadolinium enhancement (LGE) images revealed a large transmural infarction of primarily the apical segments. Within this infarcted area, a complex thrombus was identified, consisting of two distinct components separated by a layer of scar tissue (figure 3, panel B). Importantly, the LGE images also showed a small interruption in the scar tissue (figure 3, panel A), indicating a left ventricular free wall rupture with a pseudoaneurysm that was "covered" by an overlying thrombus.

Learning Points from this Case: This case highlights the unique diagnostic capability of CMR in characterizing complex myocardial thrombus and pseudoaneurysms. While TTE can detect an apical mass, it may not be sufficient to distinguish between a simple thrombus and a more complex structure, such as a contained rupture. The finding of a contained rupture, although rare, has significant therapeutic implications (1). Given the patient's comorbidities and the chronic nature of the rupture, a conservative approach with oral anticoagulation was chosen over surgical repair. This case underscores that CMR can uncover critical and unexpected findings, even in routine assessments, that are vital for guiding clinical management and assessing preoperative risk.

Panel A shows a left ventricular mass in the apex. Panel B shows the same mass in a computed tomography scan of 2018.
Early gadolinium enhancement image indicating a thrombus in the left ventricular apex.
Late gadolinium enhancement images showing that the thrombus consists of two distinct components separated by a layer of scar tissue.