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A 66-year-old man developed exertional dyspnea. The patient had undergone total arch replacement for a dissecting aortic arch aneurysm at the age of 53 and conservative treatment for myocardial infarction at the age of 60. Several imaging studies revealed a giant pseudoaneurysm that likely originated from a true ventricular aneurysm. The pseudoaneurysm severely compressed the right ventricle. Surgery was promptly performed. The patient had a history of cardiac surgery and had exclusively dense pericardium adhesion. Therefore, we incised the pseudoaneurysm and sutured the rupture orifice directly from inside the pseudoaneurysm under rapid pacing. This approach may represent an effective surgical alternative in patients with small rupture orifice and dense adhesions.

A 59-year-old man was admitted to our hospital with left hemiplegia. A computed tomography( CT) scan and echocardiography revealed a cerebral infarction in the right middle cerebral artery's territory, as well as a large pseudoaneurysm (4×3 cm) of the lateral left ventricular wall. The patient agreed to undergo cardiac surgery because of the high risk of rupture and recurrent cerebral infarctions. Owing to the high probability of damaging the posterior papillary muscle and coronary arteries, an extracardiac approach was used, and the pseudoaneurysm cavity was closed using double-patch repair. The patient was discharged from the hospital on the 12th postoperative day without any complications. Both postoperative CT and echocardiography showed closure of the cavity.

A 66-year-old man. He had myocardial infarction due to occlusion of the left anterior descending branch, which was subsequently complicated by ventricular septal perforation. Ventricular septal perforation was repaired through right ventricle incision, applying double patches for closure, and injecting glue between the patches. The early postoperative course was good, but the infarcted left ventricular anterior wall remained because of the right ventriculotomy approach. A left ventricular aneurysm was demonstrated on postoperative follow-up echocardiography, which gradually enlarged to become giant. Since symptoms of heart failure such as respiratory distress appeared, left ventriculoplasty was performed 29 months after the perforation of the initial surgery. Since thinned left ventricular wall remains following right ventriculotomy approach, risk of postoperative left ventricular aneurysm should be taken into account.

An 82-years-old woman was admitted with sudden chest pain. Coronary angiography did not reveal any significant stenosis, but left ventriculography showed akinesis and ballooning of the apex with a hyperkinetic basal segment, suggestive of takotsubo cardiomyopathy. She suffered intractable heart failure, and laboratory data, electrocardiogram signs of ST-segment elevation and left ventricular( LV) apical dysfunction failed to show improvement. LV plasty was performed on 106th day after the onset because of aneurysmal change of the left ventricular apex myocardium, unremitting sanguineous pericardial effusion, and anemia. She had a good postoperative course and end-diastolic ventricular volume index was remarkably reduced from 144 to 55 ml/m2. She discharged home on the 38th postoperative day.

We successfully performed resection of a large asymptomatic left atrial appendage aneurysm( LAAA) under non-cardiac arrest. Although the patient was asymptomatic, chest X-ray showed projection of the third left aortic arch, and computed tomography angiography showed a huge left atrial appendage aneurysm. Therefore, we decided to perform LAAA resection via a partial median sternotomy. Aneurysmectomy was performed by placing the patient on pump beating heart. The size of the resected aneurysm was approximately 80 mm in diameter. Because the base of the LAAA was constricted and the tissue was not fragile, resection was performed using an automatic excision anastomosis device( Echelon Flex). The patient's postoperative course was uneventful. Left atrial appendage aneurysm is believed to be congenital;however, it is often detected in adulthood. Long-term follow-up is necessary to ensure maintenance of optimal cardiac function.

We herein present a case of ruptured left ventriclular pseudo-false aneurysm. A 73-year-old female had acute myocardial infarction due to occlusion of the left circumflex artery, and subsequently underwent percutaneous coronary intervention. Three weeks later, however, the patient suddenly fell into a state of shock. Contrast-enhanced computed tomography (CT) revealed rupture of left ventricular aneurysm, and emergency surgery was performed. A ruptured aneurysm was observed in the posterior wall, and as the wall of the aneurysm was fragile, it was repaired using double-patch technique. Histopathological examination revealed myocardial cells in the aneurysm wall, confirming diagnosis of pseudo-false aneurysm. Pseudo-false aneurysm is a rare type of left ventricular aneurysm. In cases of rupture in acute or subacute phase of myocardial infarction, when the aneurysm wall is fragile, double-patch repair technique effectively ensures hemostasis and prevents future aneurysm formation.

We herein report a case of 71-year-old man who was diagnosed as right lung cancer associated with atrial septal aneurysm (ASA). ASA was incidentally detected on transthoracic echocardiography as a routine preoperative examination. Although upper lobectomy was performed without any postoperative event in this case, generally care must be taken for important comorbidity of cerebral infarction as a potential source of systemic thromboembolism both in pre- and post-surgery.

Membranous ventricular septal aneurysm (MSA) complicated with annuloaortic ectasia (AAE) is rare in adults. Herein, we reported two successful surgical cases of this setting. One case is 50-year-old man with extensive infective endocarditis with underwent aortic coarctation repair in childhood. MSA was incidentally diagnosed at preoperative examination. The other patient is 53-year-old man who had severe aortic regurgitation complicated with AAE and membranous type ventricular septal defect with MSA. Simultaneous surgery comprising patch closure of MSA and aortic root replacement was performed in both patients. As for patch closure of MSA, the technical modification should be necessitated according to the fragility of the upper margin of the MSA.

A 71-year-old woman was admitted for cardiac tamponade due to left ventricular free wall rupture after acute myocardial infarction. Sutureless repair was performed for bleeding from the inferior wall. Fifteen days later, computed tomography demonstrated enlargement of a left ventricular pseudoaneurysm. Patch closure using a vascular prosthesis was performed through left thoracotomy. No recurrence of the left ventricular aneurysm has been observed since.

Ventricular aneurysm after myocarditis is a rare complication. It has been reported that scarred areas of the myocardium may become aneurysm. Here, we report a case of apical left ventricle aneurysm at 18 years after the fulminant myocarditis. The patient is a 36-year-old female with a history of fulminant myocarditis at the age of 18. Eighteen years after the onset of the disease, she was referred to our hospital because of an apex ventricular aneurysm. Her computed tomography scan showed an apex ventricular aneurysm sized 45×40 mm with a wall width of 1.8 mm. We performed resection of ventricular aneurysm and reconstruction using Linear technique. The postoperative course was uneventful and discharged on the 17th post operative day.

Surgical repair of asymptomatic congenital left ventricular aneurysm is poorly reported. A 30-yearold man presented with an asymptomatic abnormal electrocardiogram. Computed tomography (CT) and angiography revealed a congenital left ventricular aneurysm, and surgical repair was conducted with endocardial linear infarct exclusion technique (ELIET). His postoperative course was uneventful. Postoperative CT showed an elliptical cardiac shape with no recurrence of aneurysm. ELIET would serve as a surgical procedure for congenital left ventricular aneurysm.

A 69-year-old man was treated with oral anticoagulation for the left ventricular (LV) aneurysm. Echocardiography revealed dyskinetic apex with a mobile thrombus. The estimated LV end-diastolic and end-systolic volume index (LVEDVI, LVESVI) was 76 and 44 ml/m2, respectively. After the LV was opened at the apex parallel to the left anterior descending artery, removal of LV thrombus was performed. LV volume was 70 ml, and diameter of LV aneurysm was 3 cm. After setting a neo-apex, the boundary between the normal and aneurysmal scar tissue were doubly encircled by a pledgeted 2-0 polypropylene suture, and preserved the same diameter as the "aneurysmal neck" (3 cm) in order to secure the minimal residual LV volume. Similarly, second and third circular stitches were placed toward the neo-apex to make the ventricle into an elliptical shape. A postoperative echocardiography showed a well-reconstructed physiologic shape, LV volume( LVEDVI 62 ml/m2, LVESVI 27 ml/m2), and improved LV function.

Aneurysms of the sinus of Valsalva are rare. We report a case of extra-cardiac unruptured aneurysm of the sinus of Valsalva with moderate aortic regurgitation (AR). A 57-year-old woman was referred to our institution because of AR. Echocardiography showed moderate AR and computed tomographic scanning demonstrated an extra-cardiac aneurysm of the unruptured sinus of Valsalva, which extended from the right sinus of Valsalva to the non-coronary sinus of Valsalva. She underwent aortic root reimplantation procedure with a Valsalva graft. Although mild AR was observed postoperatively, her postoperative course was uneventful.

This case report describes a 77-year-old man who developed infective endocarditis resulting in perforated aneurysm of the non-coronary cusp with aortic regurgitation. Diagnosis was made by transesophageal echocardiogram and successful surgical valve replacement was performed.

Subepicardial aneurysm of the left ventricle is a rare complication of myocardial infarction. We report a case of a 75-year-old woman found to have a subepicardial aneurysm 4 months after an acute myocardial infarction. The patient was admitted to our hospital with congestive heart failure, and transthoracic echocardiography and left ventriculography showed an aneurysm on the posterior wall of the left ventricle, 4.6 x 3.5 cm in size. We performed patch repair using a Hemashield graft, with coronary artery bypass grafting. She was discharged on postoperative day 69, and has been well since.

A 64-year-old woman was admitted to our hospital with acute myocardial infarction. She underwent emergent percutaneous transluminal coronary angioplasty. Transthoracic echocardiography revealed mild pericardial effusion on the third day. Pericarditis or cardiac rupture were suspected, so transthoracic echocardiography was repeated serially. On the sixth day, transthoracic echocardiography showed increasing pericardial effusion and abrupt interruption of the apical myocardium of the left ventricle and intact epicardial imaging with systolic expansion. The diagnosis was oozing type cardiac rupture of a subepicardial aneurysm. Surgical treatment was successful and the accuracy of the echocardiographic diagnosis was established.

Background: Transesophageal echocardiography (TEE) has been used to detect cardiac abnormalities including right-to-left shunt (RLS) and atrial septal aneurysm (ASA). The aim of this study was to elucidate frequency of RLS and ASA detected by contrast-TEE, and to evaluate the role of these abnormalities in stroke patients., Methods and Results: We investigated prevalence of RLS and ASA in 504 patients suspected of stroke by using TEE. (mean age 62 +/- 12 y.o., stroke 491, non-stroke 13). The RLS was detected in 64 patients (12.7%), in whom 49 patients (9.7%) had the patent foramen ovale (PFO). The ASA was demonstrated in 10 patients (2.0%), and accompanied well with the RLS (six of the 10, 60%). The prevalent ratios of the RLS (33.8%), the PFO (26.8%), and the ASA (11.3%) in 71 patients with embolic stroke (brain embolism or TIA) of unknown cause were significantly higher than those in the other 433 patients (9.2%, 6.9%, 0.5%, respectively, p < 0.0001). Multiple logistic regression analysis showed that both the PFO and the ASA were independent risk factors (odds ratio: 3.8: p = 0.0002 and 16.6: p = 0.0008, respectively) for embolic stroke of unknown cause., Conclusion: It seems that the RLS, PFO and the ASA play a roll in developing embolic stroke of unknown cause.

We reported two young adults (a 42-year-old female and a 45-year-old male) with tension type headache who had a patent foramen ovale and atrial septal aneurysm demonstrated by transesophageal echocardiography, associated with asymptomatic cerebral infarctions. There were multiple subcortical infarctions in the frontal and parietal lobes in case 1, and cerebral infarctions in the right corona radiata, head and body of the caudate nucleus, and putamen in case 2. The two cases did not have hypertension, diabetes mellitus, hyperlipidemia, cardiac diseases detected by electrocardiography and transthoracic echocardiography, and abnormality of intracranial and extracranial arteries by ultrasound sonography and cerebral angiography. Transeosophageal echocardiography revealed atrial septal aneurysm, and showed right-to-left shunt (patent foramen ovale) by Valsalva maneuver. Two cases were diagnosed as paradoxical cerebral embolism associated with a patent foramen ovale. If asymptomatic cerebral infarctions are cryptogenic stroke, a patent foramen ovale and atrial septal aneurysm should be examined by transesophageal echocardiography with Valsalva maneuver.

A rare case of aortic and mitral valve aneurysms complicated with infective endocarditis was accurately diagnosed by transesophageal echocardiography. A 57-year-old man with severe aortic regurgitation due to infective endocarditis was admitted to our hospital. Transthoracic echocardiography showed an aortic valve aneurysm on the right coronary cusp and perforations on the other cusps. Transesophageal echocardiography demonstrated a small aneurysm on the anterior leaflet of the mitral valve which was not clearly visualized by transthoracic echocardiography. Color Doppler echocardiography revealed severe aortic regurgitation and mild mitral regurgitation without perforation of the mitral valve aneurysm. Aortic valve replacement and mitral valvuloplasty of the anterior mitral leaflet were performed. The right coronary cusp of the aortic valve showed marked thinning with infiltration of inflammatory cells. The postoperative clinical course was uneventful.

A 71-year-old man was admitted to our hospital because of headache and left hemiparesis. Brain CT scan showed hemorrhagic infarction of the right frontal lobe. Intravenous digital subtraction angiography revealed no occlusion of cerebral arteries. No arrhythmias were observed by the holter ECG. Transthoracic echocardiography showed no abnormalities. Anticoagulation therapy (heparin and warfarin) was started under the diagnosis of cerebral embolism without definite embolic source and there was no recurrence during following four years. Transesophageal echocardiography showed an atrial septal aneurysm (ASA) without patent foramen ovale. A potential cause of cerebral embolism due to atrial septal aneurysm is paradoxical embolization through an interatrial shunt (patent foramen ovale). It was speculated that ASA was a direct source of thrombus formation in this case (lone ASA). Transesophageal echocardiography should be performed to find atrial septal aneurysm in patients with cryptogenic stroke, especially embolic stroke without definite embolic sources.

Echocardiographic findings, clinical features, and pathophysiology of mitral and aortic valve aneurysms were evaluated in four patients with pathologically proven aneurysms of the mitral and/or aortic valves associated with infective endocarditis. These four were selected from 20 patients hospitalized in our institute from April 1990 to May 1995 because of infective endocarditis. All four patients had received repeated, inadequate antibiotic treatments at other medical institutions prior to admission, and underwent surgical repair because of acute hemodynamic exacerbation associated with aneurysmal perforation. Six aneurysms (three mitral and three aortic valve aneurysms) were detected before surgery, including two by transthoracic echocardiography and four by transesophageal echocardiography. The echocardiographic findings typical of aortic valve aneurysm were: ringed echo at the level of the aortic annulus in the short-axis view; turbulent flow within the ringed echo; and dome formation of the aortic valve that persisted throughout the cardiac cycle. All mitral valve aneurysms were true aneurysms without active inflammatory changes or significant destructive lesions, and were associated with severe infective aortic regurgitation. Histologic examination of the aortic valve in these patients showed active inflammation and extensive destruction, suggesting that these valves were the primary focus of infection. One patient had an aortic valve aneurysm without apparent mitral involvement, indicating that another mechanism had mediated aneurysmal formation. We conclude that: diagnosis of mitral or aortic valve aneurysms in patients with infective endocarditis has important therapeutic implications, and therefore, transesophageal echocardiographic examination should be done in such patients: there are three key echocardiographically diagnostic findings of aortic valve aneurysm as mentioned above; and several unknown factors may contribute to aneurysmal formation of the mitral or aortic valve in patients with infective endocarditis.

We studied the clinical significance of atrial septal aneurysm on brain embolism. Of two-hundred twenty-eight consecutive ischemic stroke patients, 128 cases were performed transesophageal echocardiography to find cardiac lesions that could be embolic sources. Three cases were diagnosed as having atrial septal aneurysm with right-to-left shunt demonstrated by contrast echocardiography under Valsalva maneuver. These cases were all diagnosed as brain embolism from clinical courses and findings from brain CT scan, and cerebral angiography. Neurosonologic study, 24 hours Holter ECG, and transthoracic echocardiography did not reveal any other embolic sources. Paradoxical embolic mechanism is supposed to have occurred in these cases. Atrial septal aneurysm often coexists with right-to-left shunt and is clinically significant as a finding suggesting paradoxical embolism.

An echocardiography detected a large aneurysm, 10 x 15 cm in size, in the posterior wall of left ventricle in a 21-year-old male. This aneurysm could not be detected by either left or right ventriculogram. The aneurysm was opened during cardiac arrest with extracorporeal circulation, and red and white thrombi were found in it. Also the anurysm was communicated to the right atrium through a 1 x 1 cm hole, not to the left ventricle. For the complete resection of the anurysm, it was necessary to resect the left circumflex coronary artery running along the surface. The posterior wall movement in angiogram one month after surgery showed no change. Morphologically and histologically this case was similar to "Submitral annual left vetricular aneurysm" reported by Abrahams et al. 1962. It was a rare case because the anurysm was communicated to the right atrium.

A 66-year-old woman had suffered from repeated heart failure beginning 6 years after mitral valve replacement. Left ventricular pseudoaneurysm was discovered 9 years after the replacement, while no evidence including histology was obtained for the cause of the pseudoaneurysm except the mitral valve replacement. The progression of aortic valve stenosis and the formation of the pseudoaneurysm may have contributed to the onset of congestive heart failure. Surgical treatment was successful. Although left ventricular pseudoaneurysm after mitral valve replacement is rare, careful echocardiographic examination is necessary for detecting such a complication in patients after surgery.

An 87-year-old woman was admitted to another hospital with acute inferior myocardial infarction on May 31, 1991. On the 6th hospital day she suddenly developed transient complete A-V block and ventricular tachycardia. She was transferred to our hospital for the treatment of intractable heart failure on the 18th hospital day. Two-dimensional echocardiography showed a saccular chamber with a narrow-necked connection to the left ventricle. Color Doppler echocardiography showed bidirectional blood flow between the left ventricle and saccular chamber during systole and diastole. There was 35% left to right shunt in the ventricular level on right heart catheterization. Acute myocardial infarction complicated with left ventricular pseudoaneurysm and ventricular septal perforation was diagnosed. She died on the 26th hospital day without aggressive medical treatment. Autopsy demonstrated the pseudoaneurysm in the posterior wall of the left ventricle and the connection to the right ventricle. The so-called double rupture could be diagnosed before death.

A case of aneurysm of the mitral valve associated with aortic valve regurgitation is presented. The patient was 45-years-old female who complained of palpitation and underwent both aortic and mitral valve replacement. We could not detect the aneurysm by the transthoracic echocardiography because of it's small size (14 mm in diameter). The transesophageal echocardiography showed the aneurysm of the anterior mitral valve leaflet toward the left atrium clearly. This report describes that transesophageal echocardiography appears to be available for accurate diagnosis of the mitral valve disease, especially for the mitral valve aneurysm.

We report two non-surgical cases of pseudoaneurysm of the left ventricle after mitral valve replacement. Two patients underwent uncomplicated mitral valve replacement with Ionescu-Shiley and Carpentier-Edwards bioprosthesis respectively, and both had good early postoperative course with no symptoms. Left ventriculogram one month after operation showed subvalvular pseudoaneurysm of the left ventricle in both patients. Two patients were in New York Heart Association Functional Class I with digitalis and diuretics and have left ventriculogram had done five years postoperatively. Pseudoaneurysm of the left ventricle without a surgical repair disappeared in one patient, and revealed no enlargement in the other. There still remain controversies regarding the treatment of pseudoaneurysm of the left ventricle following mitral valve replacement.

Left ventricular aneurysms after myocardial infarction are generally considered one of the complications of severe coronary artery disease. Postinfarction ventricular aneurysms with normal coronary arteriogram are rare. Only a few cases have been reported previously in Japan. We examined the incidence and the clinical characteristics of postinfarction ventricular aneurysms without coronary obstruction. Among the consecutive 1800 patients studied in our laboratory with selective coronary cineangiography and left ventriography, we found 5 (4 male, 1 female) patients with left ventricular aneurysms with no or minimal coronary arterial obstruction. The patient's ages ranged from 34 to 83 with a mean of 59. Interestingly, no patient had prior anginal history, and every case occurred with a first sudden attack of chest pain. The likely mechanisms causing the development of myocardial infarction were coronary spasm and/or thromboembolic accident. One patient, in whom a coronary induction test was performed, showed positive findings. It is possible that poor collateral circulation and well preserved contraction of viable myocardium in these patients bring about the formation of left ventricular aneurysm after myocardial infarction with normal coronary arteriogram.

Aneurysms of the mitral valve complicating infective endocarditis (IE) are uncommon. The patient was a 57-year-old man who was admitted to our hospital for a precise examination of heart failure. One year before, the first two-dimensional echocardiography showed an aneurysm of the anterior mitral leaflet possibly due to a previous attack of IE. Doppler color flow mapping detected a regurgitant jet from the mitral valve aneurysm into the left atrium during systole, which suggested perforation of the aneurysm, and an aortic regurgitant jet flowing against the anterior mitral leaflet. Because the patient's family refused cardiac catheter examination and surgery, we treated him in the out-patient clinic. A few weeks before his admission, he had discontinued taking diuretics because of uncomfortable urinary frequency. He gradually developed the symptoms of heart failure and entered our hospital. IE was suspected because of leucocytosis and slight fever. Two-dimensional echocardiography revealed a new aneurysm of the anterior mitral leaflet without perforation, located in the distal part of the old aneurysm. This time, his family consented to the surgical treatment. Aortic and mitral valve replacement was successfully performed. It was pathologically confirmed that the two mitral aneurysms had been caused by IE.

A 69-year-old man who had a post-infarction left ventricular aneurysm underwent surgical repair. Preoperative left ventriculography showed a small aneurysm, 3.0 x 3.0 x 2.5 cm in size, with a narrow neck at the inferior wall suggesting a typical "false" aneurysm. But intraoperative and pathological examination revealed that this was a "true" aneurysm which contains coronary artery and myocardial cells in its wall. Left ventriculography is not necessarily the definite standard to differentiate between true and false left ventricular aneurysm.

The diagnostic accuracy of ECG gated blood pool SPECT (blood pool SPECT) for detecting and quantify postinfarction left ventricular aneurysm (LVA) was assessed in 49 patients with myocardial infarction and 15 control subjects. LVA, which was detected in 35 of 49 patients, was defined as a regional protrusion through a cardiac cycle in contrast ventriculography and as a non-contracting segment with a markedly delayed phase angle in the tomographic functional images derived from phase analysis. The blood pool SPECT technique showed a high sensitivity (100%), specificity (78.6%) and accuracy (93.3%) for detecting LVA and was very useful for precisely determining LVA location and sizing contractile and non-contractile volume of left ventricle in patients with LVA. Furthermore, left ventricular ejection fraction (LVEF) after the excision of LVA was predicted using preoperative pool SPECT images in 9 patients. The predicted LVEF was closely correlated with the measured LVEF after the operation (y = 1.09x-4.37, r = 0.87, p less than 0.01). Thus, gated blood pool SPECT can be a useful non-invasive technique not only for detecting and quantifying left ventricular aneurysm but also for predicting a residual left ventricular function after aneurysmectomy.

We prospectively studied the echocardiographic findings of an atrial septal aneurysm (ASA) to estimate its incidence and to clarify its clinical characteristics and significance. Post-mortem examination was also performed in three patients. Echocardiographically, ASA was defined as a bulging segment of the atrial septum localized in the fossa ovalis, either fixed in one direction or oscillating between the atria. It was classified in three types according to Hanley et al., i.e., Type 1A, protruding into the right atrium without oscillation; Type 1B protruding into the right atrium with oscillation, and Type 2, protruding into the left atrium with oscillation. Among 2,074 consecutive subjects in the echocardiographic study population, ASA was diagnosed in 26 patients (1.2%). This figure was slightly higher than those previously reported (0.6% to 1.0%). The extent of protrusion of the aneurysm was 8 mm or more in all patients, regardless of its direction, and it was assumed that this is a reasonable echocardiographic diagnostic criterion in the apical four-chamber view. All patients were over 51 years in age, with a mean of 71 years. Most patients (96%) had oscillation of their aneurysms. Twenty-one patients (81%) were of Type 2; one was Type 1A, and four were Type 1B. Post-mortem examination of three patients revealed septal protrusion toward the right atrium in all, and patent foramina ovale in two of them. Among the 26 patients, two (8%) had systemic embolic complications; one, cerebellar infarction, the other, cerebral infarction and mesenteric artery embolism. In conclusion, atrial septal aneurysm was observed in 1.2% of subjects undergoing routine echocardiography, with a distinctive distribution among patients over 51 years of age. Characteristically, it protrudes into the left atrium 8 mm or more, and it is sometimes associated with patent foramen ovale. Systemic embolism is a possible complication of this anomaly.

To diagnose and characterize post-infarction left ventricular aneurysms, we performed exercise thallium-201 myocardial single photon emission computed tomography (SPECT) combined with selective coronary angiography and left ventriculography. The subjects consisted of 79 patients with acute myocardial infarction; 42 with anteroseptal, three with both anterior and inferior, 29 with inferior and five with posterior infarction. Visual classification of ventricular wall morphology by either a horizontal or a vertical long-axis image was designed into convergent (C), parallel (P) and divergent (D) types, according to the interrelationship between either septal and lateral wall or anterior and inferior wall, respectively. This method was applied in post-stress and delayed images, and these patients were divided into five groups (Group A-E) in accordance with varying morphological types from the post-stress to the delayed as follows: C-C (Group A, 36 patients), P-C (Group B, 8), P-P (Group C, 7), D-P (Group D, 5) and D-D (Group E, 23). A high incidence (21/23) of a left ventricular aneurysm by left ventriculography was recognized in Group E patients in comparison with other Groups. Provided that either Group D or E (all patients had anterior infarction) had left ventricular aneurysms, the diagnostic sensitivity, specificity and accuracy were 89%, 92% and 86%, respectively. Two of three patients with false negative diagnosis had only apical involvement. Furthermore, these two Groups had significantly larger defect scores as calculated by polar maps than did the other three Groups. When patients with anterior infarction with defect scores of 200 or greater were defined positive, the sensitivity, specificity and accuracy of ventricular aneurysms were 96%, 75% and 86%, respectively. One false negative case was apical infarction, and one of the two false positive cases were extensive anteroseptal infarction involving the apex. These results suggest that a left ventricular aneurysm which is important in predicting prognostic sequence could be diagnosed only by exercise SPECT, and that it could be characterized by extensive and severe apicoanterior infarction and a divergent-type ventricular wall arrangement on a post-stress SPECT image.

It has been said that ventricular aneurysm is formed in the relatively late stage after the onset of acute myocardial infarction. We examined the time of its formation using digital subtraction angiography (DSA) performed immediately after infarction and at various intervals thereafter. We also examined correlations between aneurysm formation and the degree of rest after infarction, blood pressures, sites of infarction and coronary angiographic findings. The subjects consisted of 35 hospitalized patients with acute myocardial infarction. They were examined by DSA immediately, and one week and one month after their admissions. DSA was performed in the 30 degree right anterior oblique projection, and cardiac aneurysms were diagnosed by the presence of regional protrusion or of dyskinesis of the left ventricular wall on left ventriculography. The results were as follows: Cardiac aneurysms were noted in eight men and four women. The mean age was 69.2 +/- 8.1 years. Infarctions were located in the anteroseptal region (nine patients), in the broad anterior wall (two patients) and in the inferior wall (one patient). The average onset-to-admission interval was 5.6 hours in the aneurysm group, and eight hours in the aneurysm-free group. Cardiac aneurysms were demonstrated by DSA immediately after hospital admission in all 12 patients in the aneurysm group and the size did not increase appreciably with time. The peak CPK was significantly higher in the aneurysm group (3,163) than in the aneurysm-free group (1,655), but there was no group-related difference in risk factors, hypertension, the duration of rest after infarction, or coronary angiographic manifestations. Cardiac aneurysm has been considered as a late complication of myocardial infarction. Many investigators have reported that its formation begins one to four weeks after the onset of infarction with gradual protrusion. In the present study, however, the formation of aneurysms was complete at very early stages after the onset of the myocardial infarction and often encountered in patients with relatively extensive infarction.

Midventricular hypertrophy (MVO) is a rare and complicated myocardial disease. Its pathophysiology and prognosis remain unknown, and few nuclear cardiological findings for MVO were reported. On a 44-year old man with MVO, thallium-201 (Tl) myocardial scintigraphy and gated blood pool scintigraphy (GPS) were performed to evaluate their usefulness. GPS revealed a characteristic hour-glass deformity of the left ventricular cavity, apical aneurysm and asynchrony due to obliteration of the midventricle. Anteroseptal hypertrophy in midventricle and myocardial damage in apico-inferior region were detected by Tl. Thus, nuclear cardiological studies are proved to be useful and essential in not only diagnosis but also evaluating pathophysiology and observing natural history noninvasively.