Giant apical LV aneurysm - 3D TTE

This patient presented with shortness of breath due to ischemic heart failure. The apical transthoracic echocardiography images showed a giant apical LV aneurysm with slow vortex bloodflow within the apex. Notice the thick septal "wall of the aneurysm"....

What is the LV ejection fraction in this patient? How large is the LV and can a LV aneurysmectomy be performed in this patient? To answer these questions a three dimensional (3D) full volume dataset of 6 heartbeats was acquired and post processed using Philips Qlab.

Three dimensional rendering of the left ventricle using Philips Qlab revealed a severely dilated left ventricle with a severely reduced left ventricular systolic function (measured using the LV ejection fraction). Notice that the apical tracking is not optimal, due to near field artifacts, because the apex moves a short distance towards the basal LV (longitudinal shortening or inward movement). In this case of an apical aneurysm one would expect an outward movement of the apex like the other apical segments (dyskinetic movement of a LV aneurysm). Also, in normal hearts the LV apex has an almost fixed position and the basal LV moves towards the apex (and not the apex towards the base).

An iSlice reconstruction of the 3D full volume dataset was made. This reconstruction makes it possible to visually assess the wall motion of all LV segments at once. Short axis reconstruction of different levels are generated even at the apical level, which would be very difficult (even impossible) to image using parasternal window. Notice the crescent shape thickening of the septal wall of the aneurysm and also to a lesser extent of the lateral wall (image at the right of the middle row), compared to both the inferior and anterior aneurysmal segments, this probably is layer thrombus (remember the slow vortex flow in the aneurysm).

Multiplaner reconstruction (MPR) of the 3D full volume dataset allowed for reliable measurements of the LV length from base tot apex, because there is no foreshortening. The LV length was markedly increased with approximately 13.5 cm.

In conclusion, 3D transthoracic echocardiography can provide high quality datasets with a good spatial and temporal resolution. Multiple reconstructions of this single dataset can be made in order to obtain information about LV ejection fraction, LV dimensions, LV wall motion and different measurements (e.g. LV length) without apical foreshortening as a problem.

These images were made at the echocardiography department of Maastricht UMC+

Sebastian Streukens MD, imaging cardiologist, Maastricht UMC+