HISTORY, CURRENT DISEASE AND PHYSICAL EXAMINATION
We present the case of a 47-year-old woman with cardiovascular risk factors: hypertension, smoking and dyslipidaemia. History of chronic stable angina in functional class II without previous treatment.
She consulted a centre in the city of Buenos Aires (Argentina) due to atypical and characteristic precordial pain at rest of 1 hour's duration.
Physical examination on admission showed blood pressure (BP) 120/65 mmHg, heart rate (HR) 130 bpm, SatO2 90% on room air. Jugular ingurgitation 3/3 without inspiratory collapse. Rhythmic heart sounds, no murmurs. Regular ventilatory mechanics at the expense of tachypnoea and use of accessory muscles, generalised hypoventilation and regular bilateral air entry, with intolerance to decubitus. Good peripheral perfusion with positive symmetrical pulses. Bilateral malleolar oedema.

COMPLEMENTARY TESTS
Electrocardiogram (ECG): sinus tachycardia at 130 bpm, PR 120 ms, QRS 80 ms. ST-segment depression less than 1 mm in DII, DIII, aVF and from V3 to V6. Initial Q wave in DI and aVL with ST elevation of 1 mm.
CBC: haematocrit 29%, haemoglobin 9.5 g/dl, leukocytes 19,500/μl, platelets 212,000/μl. Baseline coagulation, renal function and ions normal. Myocardial damage markers: Troponin T US 15 ng/l and 24 ng/l (normal 0-14 ng/l). CK/CK-MB: 550/180 IU/l.
Cardiac catheterisation: right dominance. Right coronary artery without lesions. Patent anterior descending and circumflex arteries, with non-significant lesions in the middle third.
Transthoracic echocardiogram: left ventricle (LV) not dilated, mild LV systolic dysfunction. Parasternal short axis shows pseudoaneurysm in the lateral aspect of the LV.
No significant valvular heart disease.
Chest X-ray: left paracardiac radiopacity probably compatible with the location of the ventricular pseudoaneurysm, bilateral pleural effusion.
Chest CT scan: saccular image on the lateral aspect of the LV compatible with ventricular pseudoaneurysm.

CLINICAL EVOLUTION
ECG showed sinus tachycardia at 130 bpm with high lateral subepicardial lesion (image 1) and positive troponin, so emergency coronary angiography was performed, showing patent arteries with non-significant lesions in the anterior descending and circumflex arteries, so angioplasty was not performed and medical treatment was started.
After 72 hours, the patient presented with new precordial pain of intensity 10/10, and an ECG was performed with no changes with respect to the previous one and negative biomarkers. An echocardiogram was performed which revealed a ventricular pseudoaneurysm in the lateral aspect of the left ventricle, for which urgent referral to our centre for cardiovascular surgery was requested.
Chest X-ray showed left cardiac radiopacity compatible with probable pseudoaneurysm and chest CT scan showed a large saccular formation measuring 59 x 68 x 75 mm depending on the lateral wall of the LV, contained by pericardium and connected by an orifice to the myocardium with the presence of thrombi adhering to the inner wall of this formation, associated with haemopericardium and bilateral pleural effusion, predominantly on the right.
Emergency surgery was performed with closure of the aneurysm neck, placement of a Dacron patch and Prolene reinforcement at the edge of the rupture (image 6).
In the immediate postoperative period, the patient presented hypovolemic shock and subsequent right ventricular failure, which evolved favourably with volume expansion and inotropic drugs.
Prior to discharge, a new echocardiogram was performed which showed good ventricular function, with slight pericardial effusion.

DIAGNOSIS
Acute coronary syndrome with ST-segment elevation (STEMI) in the upper lateral face. Coronary arteries without acute thrombotic occlusion.
Ventricular pseudoaneurysm as a mechanical complication, with signs of imminent rupture and requiring emergency surgical repair.
