Huge Multilobulated Left Ventricular Outflow Tract Pseudoaneurysm Presenting with Ventricular Tachycardia

A 30-year-old male presented to our emergency department with recurrent episodes of syncope for one day. Pulse was feeble with a rate of 200 per minute and systolic blood pressure was 80 mm Hg. Electrocardiogram (Fig. 1) showed a monomor-phic ventricular tachycardia originating from the left ventricu-lar outflow tract (LVOT) region (Fig. 1A). Emergency 200 J synchronized defibrillator shock was given and the rhythm reverted back to normal sinus rhythm with bifascicular block (Fig. 1B). There was no history of infective endocarditis, previous cardiac surgery or chest trauma. Cardiac auscultation revealed an early diastolic murmur at the aortic area. Chest and other systemic examination was within normal limits. Cardiac markers (troponin I and creatinine phospokinase) were negative. Chest X-ray showed cardiomegaly with multiple calcified shadows within the cardiac silhouette (white arrows, Fig. 2). Poor transthoracic acoustic window necessitated transesopha-geal echocardiography, which showed a huge calcified structure near the LVOT region which was compressing the left ventricuar (LV) cavity and leading to aortic regurgitation (Fig. 3, Supplementary movie 1 and 2). To further delineate the anatomy, a multidetector computed tomography was done which showed a giant (7.0 × 9.0 × 7.5 cm), calcified, multi-lobulated and partially thrombosed LVOT pseudoaneurysm (Fig. 4). The pseudoaneurysm had its origin in the LVOT from the mitral aortic intervalvular fibrosa region and extended anteriorly, laterally and superiorly. Invasive left ventriculo-gram showed a giant calcified LVOT pseudoaneurysm with only partial filling due to thrombosis within the cavity of the pseudoaneurysm (Fig. 5A and B, Supplementary movie 3 and 4). Invasive coronary angiography showed extrinsic compression (60% diameter stenosis) of the proximal left anterior descending coronary artery (Fig. 5C and D, Supplementary movie 5). Treadmill test was done which was negative for stress induced ischemia. Patient was started on amiodarone therapy and is now planned for possible surgical correction. Pseudoaneurysms arising from LVOT region are a rare entity and exact incidence and prevalence is not known as only case reports are described in the literature. The mitral-aortic intervalvular fibrosa (MAIVF) is a fibrous triangular area in the LVOT connecting the base of the anterior mitral leaflet and the posterior aortic root. 1) The relative avascular nature of MAIVF makes it susceptible to infection and injury leading to secondary pseudoaneurysm formation. Usually a prior history of either infective endocarditis, cardiac surgical intervention, chest injury or prosthetic aortic valve implantation is present. 2) The patient in the present case was …