Magnetic Resonance Imaging of Postinfarct Septal Rupture and Left Ventricular Pseudoaneurysm
Jérôme Garot*, MD, PhD, Philippe Garot*, MD, Pascal Guéret*, MD; Alain Rahmouni†, MD.
*Federation of Cardiology and †Department of Radiology, Henri Mondor University Hospital, Créteil, France
A 80-year-old woman was referred to our institution because of recent (48 hours) AMI with subsequent Q waves in precordial leads on ECG (V1 to V6). Troponin I was mildly elevated (3 x upper normal value). On echocardiography, the apical septum was akinetic and there was a large left-to-right shunt corresponding either to an apical ventricular septal defect (VSD) or to a large pseudoaneurysm (P). Because echocardiogram could not discriminate between VSD and P, the patient who had stable hemodynamics underwent immediate cardiac cine-MRI (1.5T Siemens Symphony®) with ECG-gating and short breath-hold acquisitions, which showed an apical rupture of the interventricular septum with a jet from the left ventricular (LV) chamber into a large cavity located in front of the right ventricular apex (Figure A, systolic image extracted from cine-MRI 4-chamber view of the heart, true-fisp sequence). The kinetics of Gadolinium within cardiac chambers on ultrafast first-pass contrast-enhanced MRI (dynamic inversion-recovery true-fisp pulse sequence) ascertained the presence of a large P with late enhancement and no communication between the 2 ventricles (Figures B and C). Septal rupture is indicated by the arrow. Delayed contrast-enhanced MRI acquired 15 min after Gd-DTPA injection (T1-weighted inversion-recovery 2D gradient echo pulse sequence) demonstrated the presence of a transmural infarct located around the septal rupture (Figure D, hyper-enhancement, arrows). The patient underwent prompt surgery that confirmed complete dissection and rupture of apical LV septum along with a large anterior LV pseudoaneurysm.
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