Role of Parametric Mapping in Cardiac MRI for Chronic Left Ventricular Pseudoaneurysm secondary to Myocardial Infarction

Presenting Author(s)

• 

  Jaime Gonzalez-Medina, MD

  Cardiology Resident
  Tecnológico de Monterrey
  Monterrey, Nuevo Leon, Mexico

Primary Author(s)

• 

  Jaime Gonzalez-Medina, MD

  Cardiology Resident
  Tecnológico de Monterrey
  Monterrey, Nuevo Leon, Mexico

Co-Author(s)

• CJ

  Christian Juarez-Gaviño

  Cardiologist
  Tecnologico de Monterrey, Mexico
• ED

  Erasmo De La Pena-Almaguer, MD

  Director, Cardiovascular Service Line and CV Imaging Dpt
  Tecnologico de Monterrey
  Monterrey, Nuevo Leon, Mexico
• DL

  Daniel Lira-Lozano, MD

  Cardiology fellow
  Tecnologico de Monterrey, Mexico
• JI

  Juan C. Ibarrola-Peña, MD

  Cardiology fellow
  Tecnologico de Monterrey, Mexico
• CC

  Christian Giovanni Camacho-Mondragón, MD

  Cardiology fellow
  Tecnologico de Monterrey, Mexico
• MM

  Marisol Molina-Aviles, MD

  Cardiology fellow
  Tecnologico de Monterrey, Mexico
• MC

  Mauricio Castillo-Perez, MD

  Cardiology fellow
  Tecnologico de Monterrey, Mexico
• DB

  David Borrego-Cantu, MD

  Radiologist
  Tecnologico de Monterrey, Mexico
• JC

  Jesus Antonio Corrales-Garcia, MD

  Cardiologist
  Tecnologico de Monterrey, Mexico
• CJ

  Carlos Jerjes-Sanchez, MD

  Cardiologist
  Tecnologico de Monterrey, Mexico

Description of Clinical Presentation: We report the case of a 78-year-old woman with a long-standing medical history, including post-traumatic nephrectomy, subarachnoid hemorrhage due to ruptured cerebral aneurysm, epilepsy, and neurogenic bladder. She presented to the ER with hypovolemic shock secondary to gastrointestinal (GI) bleeding. As part of the initial approach, a bedside transthoracic echocardiogram revealed inferior and inferolateral akinesia, reduced left ventricular ejection fraction (LVEF), and discontinuity of the inferolateral wall, consistent with a pseudoaneurysm. Coronary CT angiography revealed patent coronary arteries without obstructivecoronary artery disease (CAD), and confirmed a 33 x 41 mm pseudoaneurysm involving the inferior and inferolateral walls with a 16 mm neck. Given her comorbidities, the family declined surgical treatment and was discharged upon G.I. bleeding resolution. Five months later, she presented with an ischemic stroke, prompting further evaluation.

Diagnostic Techniques and Their Most Important Findings: Cardiac magnetic resonance (CMR) revealed a larger pseudoaneurysm than previously reported, measuring 95 × 70 mm with a sizable mural thrombus of 76 × 70 mm. Mapping sequences demonstrated a heterogeneous thrombus: the external layer showed T1 values of 800 ms (compatible with a chronic organized clot). In comparison, the central portion reached T1 values up to 1500 ms (consistent with subacute blood products), confirming the coexistence of different stages of thrombus evolution. We observed a clear communication between the ventricular cavity and the pseudoaneurysmal sac. Left ventricular systolic function was severely depressed (LVEF 28%). Late gadolinium enhancement was observed involving the posterior wall. Strain analysis revealed a marked reduction in global longitudinal strain (-8%) and global circumferential strain (-3.1%). Parametric mapping of the myocardium revealed globally elevated native T1 (1327 ms), with focal inferolateral fibrosis up to 1500 ms, and globally increased T2 values (61 ms), consistent with diffuse myocardial injury and remodeling.

Learning Points from this Case: This case highlights the utility of CMR, particularly parametric mapping, in diagnosing and characterizing left ventricular pseudoaneurysms, especially in patients without obstructive CAD and no history of prior myocardial infarction. CMR allowed for a precise assessment of pseudoaneurysm size, thrombus characterization, and advanced evaluation of myocardial tissue, guiding management decisions in a high-risk patient. This case illustrates how CMR integrates anatomy, function and tissue characterization in a single exam, providing crucial diagnostic and prognostic insights in left ventricular pseudoaneurysm, insights that neither echo nor CT alone can deliver.

Fig 1. (A) T1 mapping: Short-axis view showing characterization of the pseudoaneurysmal sac and intraluminal thrombus. (B) Steady-state free precession (SSFP).
Fig 2. Steady-state free precession (SSFP): Two-chamber view showing communication between the ventricular cavity and the pseudoaneurysmal sac.