Download history of present illness

BY DR KHALID SHAHZAD
PGR
CCU III
MUHAMMAD IMRAN
 AGE: 30 years old car washer , married with 1 son
from Vehari.
 A walk in patient.
 Admitted on: 05 -12-2012 via opd.
Chief complaints:
 Shortness of breath for 6 months
 Claudications in the calve muscles -5 years
HISTORY OF PRESENT ILLNESS

SOB: of sudden onset, early morning, woke him up
from sleep. Continued for 4 hours until he received
treatment (nebs+iv inj) from a local clinic. Later, he
started developing exertional dyspnaoe which
progressively increased over 6 months period,
FC II - III.

Associated with PND, orthopnea and palpitations.

Long history of Calve muscles pain on walking on flat
for about a kilometer distance, releived on resting.

No H/O presyncope, syncope, sweating and nausea
1 month ago Left sided chest pain of sudden
onset, started at rest, stabbing in nature, non
radiating and subsided spontaneously in 4 min.
 Initially diagnosed with ashtma.
Later pulmonologist found a large heart and
referred to MIC ? Valvular heart disease.
Treated with diuretics and Inderal. No significant
relief of symptoms.

Systemic Inquiry:
 No History of Joint pains, rash, rheumatic fever,
blood disorder, chest injury.

DRUG HISTORY
 PPI
Past History
 No major CV risk factors.
 H/O high grade fever for 15 days 6 years back with dry cough,
but there was no H/O SOB at that time, Rx by GP.

FAMILY HISTORY
 Mother died after Stroke at the age of 65years.
GPE
GPE
Lying comfortably in bed , co-operative.
VITALS
Bp= 100/60
PULSE =80/Min (Sinus)
Upper limb: Right arm: absent left radial.
Lower Limb: Bilateral feeble femoral arteries, absent
popliteal, dorsalis paedis and post tibial artery pulses.
There was no evidence of vasculitis, gangrene, ulcers.
No color change noticed.
Peripheries were warm, with poor perfusion.
Temp= Afebrile
RR= 18/min
JVP: not raised
Edema: nil
Pallor: nil
SYSTEMIC EXAMINATION


CVS :
Visible apical impulse, RV heave, well sustained
heaving apical beat in 6th ICS, S1+SOFT S2,
grade II pansystolic murmur radiated to the
axillary area.

Abdomin: bruit heard above the umbilical area
in midline, there was no organomegaly, mass or
tenderness.

Chest: clear
ECG
Blood tests
IN HOSPITAL
TREATMENT
Admitted to IB
 Monitroed bed
 TAB Carvedilol 3.125 BD
 TAB Zestril 2.5 mg 1 OD
 TAB Atorvastatin 20 mg I HS
 Tab. Spiromide 20 mg OD

COURSE IN HOSPITAL
Patient remained stable
haemodynamically
 Pain free
 Mobilized gradually
 Surgical consultation- close liaison
early surgery planned.

Echo
CTangio
Cor. Angio
Abdominal USS
CT angio aorta / Lower limbs
LV Pseudo- aneurysm
A free wall rupture sealed by adherent pericardium
together with organizing thrombus and fibrous
tissue.

Causes: Most often results from transmural
myocardial infarction (particularly inferior wall
myocardial infarction) and cardiac surgery.

Rarely from: Direct chest trauma or infective
endocarditis.

Occurs more frequently in elderly patients.
Literature Review (Ref: European Journal of Echocardiography
(2008) 9, 107–109 doi:10.1016/j.euje.2007.03.043)


Common presentation:
In a series of 52 patients with pseudo
aneurysms, 48% were diagnosed incidentally.
Others presented with angina, CCF, ventricular
arrhythmias, thromboembolism.
REVIEW ARTICLE:
560 FRANCES ET AL
LEFT VENTRICULAR ANEURYSM
JACC Vol. 32, No. 3
September 1998:557–61, San Francisco and Stanford, California










290 patients with LV pseudo-aneurysms, med age:60 yrs.
Presenting symptoms: CCF (36%), chest pain (30%) and dyspnea
(25%).
Sudden death :3% of cases.
Approximately 12% were asymptomatic
Murmur found only in 70%.
ECG: None or non specific ST changes; only 20% of patients had
ST segment elevation.
CXR: Mass found in >50%.
LV angio was found to be most diagnostic test- 87% sensitivity.
2D, color and pulsed Doppler Echo had revealed some
abnormality in 85% cases while definitive diagnosis was made in
about 25 – 30 % of cases.
TEE was diagnostic in 75% of patients,
Review article- contd

CT produced some equivocal results
while MRI was quite sensitive.

Inferior infarcts were approximately
twice as common as anterior infarcts.

One third of pseudo-aneurysms resulted
from a surgical procedure, most often
mitral valve replacement.
Physical examination,
A systolic murmur can be heard when
there is an associated MR. Sometimes a
to-and-fro murmur can be noticed, which
is produced by blood flowing in and out
of the pseudoaneurysm..
Investigations:
 Although different imaging modalities exist, the most
reliable method for diagnosing LV pseudoaneurysm
is LV ventriculography.
Other imaging methods are

CXR: In >50% cases, a Para-cardiac mass in a
diaphragmatic or postero-lateral location.

TTE

TEE, Computed tomography and magnetic
resonance imaging have greater sensitivity than
TTE.
Differentiation between LV
aneurysm and pseudoaneurysms

One way of assessing this on echocardiography is by
comparing the diameter of the orifice/neck of the
aneurysm with its maximum diameter.
 In one echocardiographic series, it was found that the
ratio of the maximum diameter of the orifice to the
maximum internal diameter of the cavity was between
0.25 and 0.50 for pseudoaneurysms while the range for
true aneurysms was between 0.90 and 1.0. The presence
of turbulent flow by pulsed Doppler at the neck of a cavity
or within the cavity itself also suggests presence of a
pseudoaneurysm.
 Colour Doppler scan: pseudoaneurysm vs pericardial
effusion.
 MRI: True vs pseudoaneurysms.
Role of Coronary angio in
diagnosis

Left ventriculography will show a
paraventricular chamber filling via a
relatively narrow ostium. The diagnosis
is confirmed by demonstrating an
avascular wall on coronary
arteriography.
Treatment
Once the diagnosis is established,
urgent surgery is recommended for LV
pseudo aneurysms detected in the first 3
months after MI because the risk of fatal
rupture is relatively high.
 Published series report postoperative
mortality rates ranging between 7 and
30%.

However, management of chronic LV
pseudo aneurysms is controversial, and
risk of rupture and embolism should be
weighed against the estimated risk of
surgery.
 Moreno et al reported a cumulative
survival of 74.1% at 4 years with
conservative management of patients
with chronic LV pseudoaneurysm.

Prognosis

Regardless of treatment, patients with
LV pseudo-aneurysms had a high mortality rate,
especiallythose who did not undergo surgery.

Risk of rupture is estimated to be between 30 and 45%,
based on older studies.

Post-Op Mortality rates in patients who underwent surgery
was 23%. (JACC Vol. 32, No. 3 September 1998:557)
Prolonged survival has been observed even in a few patients
who do not undergo surgery.
Thank you