PMC5587959_01
Portable chest X-ray. Minimal cardiomegaly and minimal interstitial pulmonary vascular congestion. Possible small right pleural effusion.
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Chest X-ray demonstrated interstitial pulmonary vascular congestion (Figure 1), and EKG was sinus tachycardia with first-degree AV block.
Transthoracic echocardiogram. Small, 5 mm ventricular septal defect in the distal inferoseptal/apical septum (red arrow).
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TTE demonstrated normal biventricular systolic function, grade 2 diastolic dysfunction, and a small, 5 mm distal inferoseptal/apical VSD (Figure 2).
CT pulmonary angiogram.  6.4 x 4.3 cm peripherally calcified hyperattenuating lesion along the intraventricular groove highly concerning for a giant left anterior descending coronary artery aneurysm (red arrow).
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CTPA was without evidence of pulmonary embolism but did demonstrate a 6.4 x 4.3 cm calcified lesion concerning for giant LAD coronary artery aneurysm (Figure 3), though image quality was limited by lack of gating.
Left heart catheterization. Mild luminal irregularities of the left anterior descending artery and left circumflex arteries not requiring percutaneous intervention. No evidence of aneurysm.
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Coronary angiography revealed mild luminal irregularities only, with normal ejection fraction and no evidence of LAD aneurysm (Figure 4).
Cardiac MRI.  5.4 x 4.1 x 4.9 cm pseudoaneurysm arising from the mid-apical free wall of the right ventricle, with a 9 mm neck (red arrow). There is an adjacent muscular ventricular septal defect, which is likely related.
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Follow-up imaging was performed to elucidate these findings, and cardiac magnetic resonance imaging (MRI) clarified the anomaly as a 5.4 x 4.1 x 4.9 cm pseudoaneurysm arising from the mid-apical free wall of the RV with a 9 mm neck (Figure 5).
Cardiac CTA. Pseudoaneurysm arising superiorly from the mid-apical free wall of the right ventricle measuring up to 6.1 cm in maximal diameter with a 15 mm neck (red arrow).
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Cardiac CT angiogram was well performed and confirmed pseudoaneurysm arising superiorly from the mid-apical free wall of the RV measuring up to 6.1 cm in maximal diameter with a 15 mm neck as well as 4 x 11 mm mid-apical VSD (Figure 6).
CT pulmonary angiogram. An old healed rib fracture anterior to the pseudoaneurysm (red arrow).
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A review of the previously performed CTPA was conducted at this point and revealed a previously healed rib fracture anterior to the pseudoaneurysm (Figure 7).