A pseudoaneurysm results from a rupture of the ventricular wall with the containment of the resultant hematoma by pericardium or extracardiac structures [6]. It may occur after cardiac trauma, congenital heart surgery, endomyocardial biopsy, pacemaker placement, infections, post-myocardial infarction, and central venous or pulmonary artery catheterization [2]. For decades, Swan-Ganz catheter is used for measuring cardiac filling pressure and the incidence of its known complications is less than 1%, which includes the rapture of the pulmonary artery, knotting, and right ventricular free wall perforation [2, 7]. Our case describes a right ventricular pseudoaneurysm after right heart catheterization in a patient with right heart failure in the setting of an atrial septal defect. Initial imaging demonstrated no clear evidence of pseudoaneurysm or compressive effects on the right ventricle and its determination was made upon further evaluation with cardiac CT angiography, which has high spatial resolution than transthoracic echocardiography.
Most of the patients with cardiac pseudoaneurysm have no typical clinical presentation and some are asymptomatic [8]. Symptoms may include mediastinal mass effect, thromboembolism, arrhythmia, chest pain, and rupture. As the pseudoaneurysm slowly increases in size, the compressive effects get worse [3, 9]. Our patient presented with chest pain and dyspnea after exertion that could be due to pulmonary hypertension resulting from the preexisting atrial septal defect.
Multiple imaging modalities including echocardiography, CT, and MRI can be used for the diagnosis of ventricular pseudoaneurysm [4]. Echocardiography is the first-line method for diagnosis because of its easy availability and routine usage but has low sensitivity [3]. However, in our case echocardiography failed to detect RV pseudoaneurysm. An ECG-gated CT scan can provide more detailed anatomic information, size, neck, and origin of pseudoaneurysm as well as the myocardial enhancement pattern [10]. Cardiac MRI can be used to obtain functional and anatomic information [6]. Both CT and MRI are non-invasive with a high special resolution, which improve the visualization of segments that may be difficult to see on echocardiography [3]. In our case, the CT and MRI provided vital information for an accurate diagnosis. The right ventricular pseudoaneurysm can be successfully managed with conservative treatment. However, in high-risk patients with tamponade, severe pulmonary hypertension, and hemodynamic deterioration the surgical intervention or percutaneous closure is the mainstay of treatment [1, 10]. Although this is a rare and surgically proven case, lack of longtime follow -up may be the only limitation for this case report.