Sawfish left ventricle: acute myocarditis presenting with left ventricular aneurysm
Department of Cardiology, Catholic University of Sacred Heart, Largo A. Gemelli 8, 00168 Rome, Italy
* Corresponding author. Tel: +39 6 30154187; fax: +39 6 3055535. E-mail address: mauriziopieroni{at}yahoo.com
A 41-year-old female patient with no previous history of cardiovascular disease nor cardiovascular risk factors was admitted to the emergency department for typical chest pain associated with diffuse non-specific ST-segment changes and an increase in CK-MB and troponin T. Two-dimensional echocardiography showed normal dimensions and function of the left ventricle (LV). The patient was therefore submitted to coronary angiography which showed normal coronary arteries, whereas LV angiography showed the presence of a small localized aneurysm in the posterobasal segment of the LV and a larger aneurysm with a cylinder shape and multiple lateral prickles resembling the aspect of the saw of a sawfish (Panels A–C). Ergonovine provocative test failed to induce coronary spasm of both left and right coronary arteries. Multiple endomyocardial biopsies obtained in the regions close to the apical aneurysm showed the presence of active lymphocytic myocarditis (Panel D). No viral genome was detected at PCR on frozen myocardial samples.
In the following days, the patient remained asymptomatic with preserved LV function, while occasional ventricular ectopic beats with right bundle branch block morphology were observed at Holter monitoring.
Acute myocarditis may mimic an acute coronary syndrome and may cause localized LV aneurysms often associated with ventricular arrhythmias. As small ventricular aneurysms may not be recognized at two-dimensional echocardiography, LV angiography should be performed in patients presenting with chest pain and/or ventricular arrhythmias and normal coronary arteries, in order to better address further clinical investigation.
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