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Left ventricular aneurysm in a child: A ticking bomb. Abstract ID: IRIA - 1063.

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Presentation on theme: "Left ventricular aneurysm in a child: A ticking bomb. Abstract ID: IRIA - 1063."— Presentation transcript:

1 Left ventricular aneurysm in a child: A ticking bomb. Abstract ID: IRIA - 1063

2 INTRODUCTION Left ventricular aneurysm is an extremely uncommon finding in the paediatric population. Causes may be congenital or acquired, [1] and include trauma, myocarditis, myocardial infarction and endocardial fibroelastosis. [1],[2],[3] We report a case of left ventricular aneurysm in a nine year old male child who presented with an acute onset of chest and upper abdominal pain.

3 CASE REPORT A nine year old boy presented with an acute onset of chest and upper abdominal pain of three hours duration. There was history of trauma two years prior to presentation. On examination the boy was tachycardic and dyspnoeic with faint heart sounds. Electrocardiogram revealed T wave inversion in the lateral leads suggestive of ischaemia. Echocardiogram showed a hypokinetic left ventricle with a large aneurysmal sac measuring 6 x 3 cm arising from the left ventricle, with fluid in the pericardial cavity.

4 CASE REPORT Chest radiography revealed an ovoid mass with peripheral calcification overlapping the cardia and upper abdomen, increased cardiothoracic ratio, and an ill defined haziness in the left lower lung zone. [Figure 1] Contrast enhanced computed tomography showed a contrast filled aneurysmal sac arising from the left ventricle measuring 6 x 3 cm with calcified walls, with a defect in the inferior wall of the sac showing leakage of contrast suggestive of rupture. Also noted were haemopericardium and a left lower lobe consolidation. [Figures 2 and 3]

5 Figure 1 Chest x ray PA view showing an oval shaped mass overlying the cardia and upper abdomen with calcified walls(yellow arrows). Cardiomegaly and ill defined haziness of the left lower lung zone are also noted.

6 Figure 2 Contrast enhanced CT in coronal reconstruction showing the aneurysmal sac(sac) arising from the left ventricle(LV). Also seen is the calcified wall of the aneurysm, and the defect in the inferior wall with leakage of contrast. sac LV Calcified wall of the aneurysm Defect in the inferior wall

7 Figure 3 Contrast enhanced CT in sagittal reconctruction showing the aneurysmal sac(sac) with calcified walls, arising from the left ventricle(LV). The defect in the inferior wall of the sac, left lower lobe consolidation and haemopericardium are also seen. sac LV consolidation haemopericardium Calcified wall of the aneurysm Defect in the inferior wall

8 CASE REPORT A diagnosis of a ruptured left ventricular aneurysm with haemopericardium was made and the child was started on supportive treatment and anti-coagulation therapy. Surgery was advised but the patient was discharged against medical advice.

9 DISCUSSION Ventricular aneurysms are unusual in the pediatric population. Causes may be congenital or acquired. [1] Congenital causes include myocarditis, endocardial fibroelastosis and ischaemic injury to the myocardium during the fetal period. [1],[2] Acquired causes include trauma, myocardial infarction, infection and surgery. [3]

10 DISCUSSION The predisposing conditions leading to the formation of a post traumatic ventricular aneurysm include myocardial contusion, vascular injury to the left anterior descending coronary artery leading to ischaemia, and an intramyocardial dissection. [4]

11 DISCUSSION The mechanism of cardiac injury may either be a direct compression of the cardia between the sternum and vertebral column, or a “hydraulic ram effect”,wherein a sudden increase in the intrathoracic pressure from abdominal and lower extremity compression results in trauma. [3]

12 DISCUSSION Ventricular aneurysms can be of the true or the false type. A true ventricular aneurysm is one in which the wall is formed by the scarred myocardium. These can occur either due to transmural myocardial contusion and necrosis or trauma-induced thrombosis of coronary vessels causing ischemic necrosis. [3],[5],[6] A false aneurysm consists of a hematoma from ventricular rupture contained by pericardium, and usually follows penetrating trauma. [3],[5 ],[6]

13 DISCUSSION The demonstration of the aneurysmal sac communicating with the ventricle is diagnostic. [3] Other features such as wall calcification and a haemopericardium may be seen. Indirect signs such as an old rib or sternal fracture may point towards a post traumatic cause.

14 DISCUSSION Our patient presented with a remote history of blunt trauma with acute onset of breathlessness and chest pain. The calcified wall points to a long standing process. The ruptured aneurysm with haemopericardium explain the acute symptoms of the child.

15 CONCLUSION The causes of chest pain in a child are varied, with non cardiac causes being the most common. When there is a history of trauma, it is important to consider cardiac causes for the chest pain such as myocardial contusion, valvular injury and ventricular aneurysm.

16 REFERENCES 1.Ercan A, Senkaya I, Semizel E, Cil E. Left ventricular aneurysm in a 4-year-old boy. Tex Heart Inst J Tex Heart Inst St Lukes Episcop Hosp Tex Child Hosp. 2005;32(4):614–5. 2.Gerlis LM, Partridge JB, Fiddler GI, Williams G, Scott O. Two chambered left ventricle. Three new varieties. Br Heart J. 1981 Sep;46(3):278–84. 3.Veeragandham RS, Backer CL, Mavroudis C, Wilson AD. Traumatic left ventricular aneurysm and tricuspid insufficiency in a child. Ann Thorac Surg. 1998 Jul;66(1):247–8.

17 REFERENCES 4.Kadner A, Fasnacht M, Kretschmar O, Prêtre R. Traumatic free wall and ventricular septal rupture - “hybrid” management in a child. Eur J Cardio-Thorac Surg Off J Eur Assoc Cardio-Thorac Surg. 2007 May;31(5):949–51. 5.Stephenson JD, Hulse MA. Combination of traumatic thoracic aortic pseudoaneurysm and myocardial contusion leading to left ventricular aneurysm. Pediatr Radiol. 2006 Mar;36(3):258–62. 6.Silver GM, Spampinato N, Favaloro RG, Groves LK. Ventricular aneurysms and blunt chest trauma. Chest. 1973 Apr;63(4):628–31.

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