Clinical profile and outcome in 52 patients with cardiac pseudoaneurysm

Background: Cardiac pseudoaneurysm, a contained cardiac rupture, predisposes patients to further rupture. However, knowledge of the clinical profile and natural history of this cardiac complication is limited. Objective: To study the clinical features and outcomes of patients with cardiac pseudoaneurysm. Design: Retrospective analysis of patients with cardiac pseudoaneurysm seen between January 1980 and September 1996. Setting: Mayo Clinic in Rochester, Minnesota; Scottsdale, Arizona; and Jacksonville, Florida. Patients: 52 patients with pseudoaneurysm. Results: Pseudoaneurysm was discovered incidentally in 25 asymptomatic patients (48%). Four patients (8%) presented acutely (3 with acute myocardial infarction and 1 with cardiac tamponade). Other clinical presentations were congestive heart failure in 8 patients (15%), chest pain in 7 (13%), syncope or arrhythmia in 5 (10%), and systemic embolism in 3 (6%). Initial diagnostic tests were echocardiography in 32 patients, cardiac catheterization in 12, magnetic resonance imaging in 4, and computed tomography in 2. Diagnosis was made intraoperatively in two patients. Pseudoaneurysm occurred after cardiac surgery in 30 patients (58%) and after myocardial infarction in 22 (42%). Location of the pseudoaneurysm was primarily related to its cause: Pseudoaneurysm was located in the inferior or posterolateral wall in 18 of 22 patients (82%) after myocardial infarction, in the right ventricular outflow tract in 13 of 15 patients (87%) after congenital heart surgery, in the posterior subannular region of the mitral valve in 4 of 4 patients (100%) after mitral valve replacement, and in the subaortic region in 3 of 3 (100%) after aortic valve replacement. Forty- two patients (81%) had surgical repair (surgical mortality rate, 7%). Ten patients (19%) did not have surgery. Nineteen patients died after a median survival of 2.3 years (range, 3 days to 8.2 years): Eight died of noncardiac cause, 5 of congestive heart failure, 4 of acute myocardial infarction, and 2 of cardiac arrhythmia (ventricular tachycardia). No further cardiac ruptures were documented. Conclusions: A substantial number of patients with pseudoaneurysm are asymptomatic. Although surgical repair is the treatment of choice, conservative management in selected patients with increased surgical risk seems reasonable because no deaths were caused by further rupture.