Strategic DAPT Interruption for Enlarging LV Pseudoaneurysm After Myocardial Infarction in a Dialysis Patient

BACKGROUND: Left ventricular pseudoaneurysm following acute myocardial infarction carries a high risk of rupture and typically requires surgical repair. CASE SUMMARY: A man in his 40s on maintenance hemodialysis presented with lateral-wall ST-segment elevation myocardial infarction during dialysis. Primary percutaneous coronary intervention successfully recanalized the occluded left circumflex artery. On day 26, echocardiography revealed a 15-mm left ventricular pseudoaneurysm that enlarged to 19 mm by day 38 (≈30% increase). Given prohibitive surgical risk due to multiple comorbidities and multidisciplinary heart team assessment, conservative management with strategic complete interruption of dual antiplatelet therapy was undertaken on day 39. Complete thrombosis occurred by day 53 without complications. Aspirin monotherapy was resumed on day 56. The 21-month follow-up demonstrated complete absorption. DISCUSSION: Progressive enlargement rendered continued conservative observation insufficient. Following careful multidisciplinary evaluation in a surgically prohibitive, high-risk patient, strategic interruption of dual antiplatelet therapy was associated with complete thrombosis. TAKE-HOME MESSAGES: Small left ventricular pseudoaneurysms in high-risk patients may be managed conservatively with intensive surveillance. Rapid enlargement may signal impending rupture and, in selected cases with multidisciplinary consensus, warrant consideration of strategic dual antiplatelet therapy interruption.