A multifactorial aetiology for dilated cardiomyopathy
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An asymptomatic 44-year-old male patient was referred to our institution for cardiological evaluation to start antiviral treatment. He had a history of parenteral drug-abuse, chronic hepatitis C virus infection, and various episodes of right heart endocarditis managed medically. The electrocardiogram showed Q-waves, 1-mm ST elevation, and negative T-waves in precordial leads.

The transthoracic echocardiogram revealed severe left ventricular (LV) enlargement and dysfunction. Coronary angiography demonstrated a chronic total occlusion of the mid-left anterior descending coronary artery. Cardiac magnetic resonance showed: (i) a large LV apical aneurysm which represented half of the LV volume, with a laminar thrombus attached; (ii) a bicuspid aortic valve with severe regurgitation and (iii) a perimembranous ventricular septal defect (VSD) with a significant left to right shunt (pulmonary-systemic flow ratio of 1.9).

The heart team decision was to perform a modified Dor aneurysmectomy, VSD repair, and aortic valve replacement with a bioprosthesis. Myocardial revascularization was not considered due to the necrotic nature of the aneurysm.

In unrecognized non-reperfused myocardial infarctions, embolic or arrhythmic complications are frequently the first manifestation of LV aneurysm. In these patients, multimodality imaging is crucial to assess the anatomy and rule out unnoticed thrombi.

Authors present a case of a giant incidental LV aneurysm in which the additional concurrence of two volume overload conditions may have probably contributed to the poor remodelling and expansion of the original ischaemic lesion.

Source: https://academic.oup.com/ehjcr/article/5/6/ytab104/6289836