Title : Therapeutic pneumoperitoneum mimicking inferior myocardial infarction and right ventricular aneurysm: A case report
Abstract:
Introduction: Progressive preoperative pneumoperitoneum (PPP) expands abdominal capacity before repair of giant loss-of-domain hernias. Pneumoperitoneum can alter diaphragmatic position, cardiac orientation and ventricular loading, producing pseudo-infarction ECG changes; an associated right ventricular (RV) aneurysm-like appearance is rarely described [1-5].
Case presentation: A 76-year-old man with diabetes and no cardiac symptoms had a giant left inguinoscrotal hernia, with 49% of measured volume within the hernial sac. Following abdominal-wall botulinum toxin, a peritoneal pigtail was placed, and PPP was administered from 27 May to 4 June 2026 (500-1200 mL air/day). ECG on 4 June showed sinus tachycardia (114 bpm), abnormal inferior Q waves in II, III and aVF, and nonspecific anterior T-wave changes (Figure 1A). Preoperative echocardiography showed an RV apical aneurysmal appearance (Figure 1C). CMR on 5 June demonstrated focal RV free-wall thinning/outward bulging with dyskinesia and >75% subendocardial late gadolinium enhancement, raising RV infarction or arrhythmogenic RV cardiomyopathy as differentials; the study was limited by poor breath-holding. Coronary angiography showed normal, non-obstructive coronary arteries. Anatomical hernia repair with left orchidectomy was performed on 8 June. Postoperatively, the inferior Q-wave pattern was no longer evident, although nonspecific
anterior T-wave changes persisted (Figure 1B). Echocardiography on 11 June showed a normal RV, no LV regional wall-motion abnormality, and preserved biventricular systolic function (LVEF 60%) (Figure 1D).
Conclusion: The reversible inferior ECG pattern, postoperative normalization of RV morphology on echocardiography, normal coronary anatomy and temporal association with PPP support a pneumoperitoneum-related pseudo-infarction/mechanical mimic. PPP should be considered when new inferior ECG or RV abnormalities arise after insufflation, with repeat assessment after decompression or definitive repair before diagnosing fixed ischaemic or RV structural disease.
