HISTORY, CURRENT ILLNESS AND PHYSICAL EXAMINATION

BACKGROUND:
Arterial hypertension. Dyslipidaemia. No known diabetes mellitus. Chronic ischaemic heart disease.
Acute myocardial infarction with ST-segment elevation (STEMI) evolved in December 2016. Due to refractory angina, scheduled percutaneous angioplasty was performed with implantation of a stent covered by a thrombotic occlusion of the proximal right coronary artery. Chronic under-occlusion of untreated first obtuse marginal (fine calibre vessel). Echocardiography at discharge showed a slightly dilated left ventricle (LV) with mild concentric hypertrophy and a large area of akinesia/dyskinesia in inferior and inferolateral segments with an image of a large pseudoaneurysm and abundant thrombotic material lining the walls of the pseudoaneurysm. Normal contractility of the rest and moderately depressed residual left ventricular ejection fraction (LVEF) (40%). Discharged with triple therapy with acenocoumarol, without resolution of the intracavitary thrombus on echocardiography 6 months after discharge.
Other pathologies: stage 3B chronic kidney disease. Fontaine grade IIb peripheral arterial disease. Alzheimer's type dementia.
Current treatment: acenocoumarol, acetylsalicylic acid (ASA) 100 mg/24 hours, bisoprolol 5 mg/24 hours, ramipril 2.5 mg/24 hours, furosemide 40 mg/24 hours, atorvastatin 80 mg/24 hours, omeprazole 20 mg/24 hours.
Functional status: New York Heart Association (NYHA) functional class II. Moderate cognitive impairment. Bed-chair life.
Family history: brother with acute myocardial infarction (AMI) at 51 years of age.

CURRENT ILLNESS:
Patient attended for a check-up of his ischaemic heart disease. No recurrence of angina, although her physical activity is very limited, she only reports dyspnoea with postural changes. No relevant bleeding under triple therapy, she discontinued clopidogrel one year after starting it.

PHYSICAL EXAMINATION:
Weight 78.0 kg. Height 165 cm. Blood pressure (BP) 98/56 mmHg. Heart rate (HR) 67 bpm.
Oxygen saturation (SatO2) 96%. Cardiac auscultation: rhythmic heart sounds, no murmurs.
Pulmonary auscultation: preserved vesicular murmur (VCM) without pathological additions.
Abdomen was nondescript. Lower extremities without oedema or signs of deep vein thrombosis (DVT). Normal pulses.

COMPLEMENTARY TESTS
Recent ANALYTICS: glucose 108 mg/dl, urea 32 mg/dl, creatinine 1.45 mg/dl, bilirubin 0.7. GOT 21.0. GPT 28.0 g/dl. Total cholesterol 155 mg/dl, triglycerides 123 mg/dl, HDL cholesterol 43 mg/dl, LDL cholesterol 98 mg/dl. Sodium 141 mEq/l, potassium 4.6 mEq/l. Haemoglobin 15.4 g/dl, haematocrit 44.5%, MCV 84.3 fl, platelets 237.0 10e3/ul, leucocytes 6.73 10e3/ul, HbA1c 5.6%.
ELECTROCARDIOGRAM (ECG) performed in consultations: sinus rhythm at 66 bpm, PR < 200 ms, QRS 110 ms, QRS 110 ms, Q wave in inferior derivations with ST supradelevation of up to 1.5 mm and negative inferolateral T wave.
Recent echocardiography: inferior basal and posterior basal dyskinesia, akinesia of mid posterior septum. Hypokinesia of the medial lateral face. The described dyskinetic areas present an image of a large pseudoaneurysm with an image of thrombotic material inside.
Normal contractility of the rest and moderately depressed residual LVEF that is not quantified by the presence of aneurysm, visually estimated at 35-40%. Slight valvular degenerative signs, with preserved opening. Left atrial dilatation. Slight pericardial effusion in the area adjacent to the posterior face, with no evidence of haemodynamic compromise. Inferior vena cava and suprahepatic vein not dilated, with adequate inspiratory collapse, which excludes the presence of significant systemic venous hypertension.
CARDIAC MAGNETIC RESONANCE: a saccular image of approximately 4.8 x 4.4 cm communicating directly with the left ventricular cavity, showing an abrupt change in the contour of the LV wall, inferior and inferolateral basal location compatible with LV pseudoaneurysm. It shows a wide neck of 3.6 cm. In the gradient echo sequence with long TI (550 ms) after administration of IV contrast, a hypointense image with crescent morphology is seen in its interior, approximately 13 mm in maximum thickness, compatible with thrombus. Late enhancement sequences do not show hyperintense areas suggestive of necrotic myocardial wall-forming tissue. Moderate-severe LV dysfunction (LVEF 35%). Mild aortic and mitral regurgitation.

CLINICAL EVOLUTION
Given the morphological findings described in the complementary tests, the possibility of surgical intervention of the pseudoaneurysm was considered. This option was finally rejected in consensus with the patient, given the high comorbidity and clinical stability since discharge (no episodes of decompensation due to heart failure, ventricular arrhythmias or recurrence of angina). Instead, a strategy of clinical follow-up and periodic imaging techniques was proposed to assess signs of progression or alarm.
In this regard, during follow-up, the absence of resolution of the intraventricular thrombus was confirmed under adequate anticoagulant therapy (time in INR 2-3 range > 60%). Therefore, considering the low risk of embolisation given its morphological characteristics and the patient's high risk of bleeding, anticoagulant treatment was definitively withdrawn.
Finally, ezetimibe 10 mg/24 hours was added to the treatment to try to achieve target LDL cholesterol concentrations (< 70 mg/dl).

DIAGNOSIS
Chronic ischaemic heart disease. Advanced inferior STEACS. Revascularisation with drug-eluting stent to proximal right coronary artery.
Left ventricular pseudoaneurysm with intracavitary thrombus image. Moderate ventricular dysfunction.
