 Hello everyone, I am Dr. Varad Deshmukh, junior resident of radiology in Government Medical College, Mirats. Today I am going to present a rare case of fetal left ventricular leaking aneurysm with hemopericardium. So to begin with, prenatal diagnosis of fetal anomalies have been made possible in the era of ultrasonography and magnetic resonance imaging without any intervention to either mother and fetus. Fetal cardiac anomalies like ASD, VSD, TDA and tetralogy of phallid, etc. have overall incidence rate of 8 to 12 per 1,000 livers. Almost all fetal anomalies can be diagnosed in prenatal period with imaging. Left ventricular leaking aneurysm is an uncommon condition and early diagnosis by ultrasonography helps in the prognostication and counseling of the parents. Left ventricular aneurysm with associated hemopericardium is a very rare and highly lethal anomaly with an incidence rate of 0.5 per 1 lakh livers and only one case reported in the literature till date. So here we present this case diagnosed on prenatal ultrasonography at 19 weeks of the gestation in G2P0A1 female with its characteristic echocardiographic findings. Ames to emphasize the importance of the detailed prenatal fetal ultrasonography in early diagnosis of the lethal congenital cardiac anomalies like fetal left ventricular apical leaking aneurysm with prognostication and counseling of the parents and managing the outcome by the multidisciplinary approach. Methodology. A 34 year old woman G2P0A1 was referred for the second trimester oxidic anomalies scan as on her previous scan cardiac abnormality with the ventricular contraction irregularity was noted. The detailed fetal echocardiography examination was done at R Institute. Antenatal ultrasonography with fetal cardiac echo was done with a convex probe of 4 MHz high frequency transducer on Canon Aplio 400 system. So moving towards the case a 34 year old woman G2P0A1 was referred for the second trimester oxidic anomalies scan as on her previous scan cardiac abnormality with ventricular contraction irregularity was noted. Patient was asymptomatic and was not on any treatment as per history narrated by her and was not exposed to the teretojones or radiation during her pregnancy. Patient had a previous history of a spontaneous abortion two years ago at the gestational age of 20 weeks which was followed by check care attach. As per history given by the patient she did not have any exposure to teretojones or any recent infection or any other predisposing risk factor associated as per the best of the her knowledge. The detailed fetal echo was performed with patient's consent and as per the referring physician's advice. Results. On fetal echocardiogram attained by 5.9 mm in wall aneurysm was seen arising from the apex of the left ventricular wall with neck measuring 2.2 mm. The aneurysm volume in the diastole was 0.9 mm. The ratio of the aneurysm volume to left ventricular volume in the diastole was 0.7. On color flow imaging there was a low velocity turbulent flow noted in the aneurysmal sag however there was no evidence of contraction of the aneurysmal pouch in the systole. A 0.9 mm rent was noted in the wall of aneurysm with minimal leakage of blood in the pericardial space during the systole. Pericardial effusion of thickness 4.3 mm was noted. Rest of the fetal anatomy including the walls were normal in the morphology and showed normal form on the M and PW modes. So here we can see the images. In first image we can see four chamber view of the heart with the aneurysm. These are the ventricles right ventricle left ventricle adjacent to which there is an aneurysmal sag and this cavity is the pericardial gap. These are the anterior. In the image in this image A denotes the neck of the aneurysm, B denotes the rent in the aneurysm, C denotes the aneurysmal pouch which is narrow neck and D is the pericardial space. This rent was in the hemopericardium. Few other images in which flow imaging with the blood in the aneurysm is seen and blood leaking into the pericardium by the rent which is denoted by BEC. So results due to significant leak from the aneurysm in this case fetal cardiac compromise was already set in before the diagnosis which later progressed to fetal hydrox. So pregnancy was terminated. Patient was explained the risk and outcome of the pregnancy so she opted for the medical termination of the pregnancy at 21 weeks of the gestation in a tertiary care hospital. The clinical autopsy of the fetus was performed by a team of the obstetricians which showed gross hemopericardium and apical left ventricular aneurysm as shown in the images confirming the antenatal solar ultrasonography diagnosis. So these images are showing the clinical autopsy in which first image shows the hemopericardium, second image shows the anterior view of the heart, third image shows the aneurysm arising from the apex of the heart and the last image showing the rent in the aneurysm site causing the hemopericardium. Going to the discussion ventricular aneurysm in the fetus is a rare anomaly having an incidence rate of 0.5 per 1 lakh libraries. This case is the second in the English literature where the ventricular aneurysm was seen leaking in the pericardium diagnosed on the ultrasonography. To the best of our knowledge no etiological factor would be associated except for the maternal age. The close differential diagnosis of the ventricular aneurysm is a ventricular diverticulum to differentiate between the two flu imaging is done. A ventricular aneurysm is a permanent abnormal dilatation of the ventricular wall which lacks the property of the contraction. Wall of the aneurysm is a sac-like structure made up of fibros dream of the tissue or dilated thin ventricular wall which makes it incapable of the contraction and relaxation differentiating it from the ventricular diverticulum which is a continuation of the ventricular wall with the same histology. A diverticulum is a narrow projection which synchronously contracts with the ventricular system. Ventricular aneurysm is usually not associated with other caradib or thoracobdominal anomalies but a ventricular diverticulum can be specifically arising from the apex and is usually associated with some other intra-caradib or midline pericobdominal syndromic anomalies. Prognosis of both anomalies also differ and so does their treatment. A diverticulum without any association to the other anomalies usually have the favorable prognosis after the repair but in case of the aneurysm prognosis depends on the size, origin, involvement of the valves and contractility of the rest of the ventricular. Etiopathogenesis of the aneurysm mostly involves the focal thinning of the ventricular wall due to the myocardial ischemia or an infection. Size of the aneurysmal sac is important prognostic factor as it will increase the gestational age. Aneurysmal leak carries poor prognosis as the gestational age increases more blood gets collected in the pericardial cavity further compressing the ventricles and thus compromising the cardiac output which in turn will cause less blood supply to the other fetal organs eventually leading to the fetal growth retardation, anemia and the fetal hydrops. To improve the outcome of the pregnancy in ventricular aneurysm or multidisciplinary team approach from the maternal and fetal medicine, interventional radiology, neonatology, pediatric cardiology and pediatric cardiac intensive care can be offered to the patient. Early diagnosis with the fetal ecocardiography and management of the leaking aneurysm with in utero USG guided pericardiocentesis may reduce the pressure over fetal myometrium, improving the functionality and decreasing the risk of the temponid or hemopericardium significantly. Continuous antenatal surveillance with the help of USG is needed till the term. So normal vaginal delivery can cause transient episodes of fetal decelerations and risk of the fetal hypoxia which may proven fatal in case of the leaking aneurysm by increasing the systemic and the pulmonary vascular resistance. So elective caesarean section provides a safer way and prevents the factor predisposing the rupture of the ventricular aneurysm during the normal vaginal delivery. Early cold clamping causes early closure of the ductus arteriosus by increasing systemic vascular resistance, but in such cardiac conditions right to left shunting of the blood is necessary till the normal respiration of the fetus sets in. So delayed cold clamping is recommended here. Intravenous PG even infusion is also given to maintain the ductal patency so as to decrease the systemic vascular resistance which if raised significantly might precipitate the rupture of aneurysm. A definitive cardiac surgery comprising of the aneurysmal resection and patch repair to be performed so as and when planned to correct the aneurysm. Moving to the conclusion, left ventricular apical leaking aneurysm with hemopericardium is a very rare anomaly which can be diagnosed easily on the prenatal ultrasonography. An advanced maternal age can be considered as a risk factor in above mentioned case and a multidisciplinary approach can help in improving the fetal and the maternal outcome and the well-being. Here are my references. Thank you so much.