Aneurysm, Pseudoaneurysm, Diverticulum, or Other? Discordance Between Multimodality Imaging and Surgical Findings in a Patient with Coronary Artery Disease

Background: Left ventricular outpouchings remain among the most difficult structural abnormalities to classify in clinical practice. The differential diagnosis usually includes true aneurysm, pseudoaneurysm, diverticulum, and less clearly defined chronic post-ischemic remodeling patterns. Although multimodality imaging is central to preoperative assessment, it may still overstate diagnostic certainty in complex chronic lesions. Case Presentation: We report the case of a 66-year-old man with chronic coronary syndrome and severe multivessel coronary artery disease in whom transthoracic echocardiography, computed tomography, ventriculography, and cardiac magnetic resonance consistently suggested a basal lateral left ventricular pseudoaneurysm, with imaging findings compatible with an associated mural thrombotic component. Because of the coexistence of surgically significant coronary disease, the patient was referred for operative treatment. Intraoperatively, however, the expected pseudoaneurysmal cavity was not identified. Instead, two posterolateral fibro-calcific left ventricular formations were found in a surgically difficult area, with an appearance that did not correlate convincingly with any preoperative imaging study. Given their calcified aspect, difficult exposure, and the high risk of additional surgical manipulation, no direct intervention was performed on these structures, and only myocardial revascularization was undertaken. The postoperative course was favorable. Discussion: The case highlights a clinically important limitation of multimodality imaging: concordant imaging does not necessarily equal an anatomically correct diagnosis. The discrepancy between imaging and operative findings raises unresolved questions as to whether the lesion represented small chronic aneurysmal formations, an unusual chronic pseudoaneurysm, a calcified diverticular process, multiple fibro-calcific post-infarction outpouchings, or another form of chronic left ventricular remodeling. Rather than forcing a definitive label unsupported by pathology, the case is better understood as a diagnostic gray-zone lesion. Conclusions: Even comprehensive imaging may remain incomplete when evaluating unusual left ventricular outpouchings in ischemic patients. This case underscores the need for cautious diagnostic language, close correlation with operative findings, and broader discussion regarding the classification of chronic left ventricular parietal lesions.