[Survivor of blow out type of free wall rupture: multislice computed tomographic detection of myocardial rupture in a case of small myocardial infarction]

A 73-year-old man was admitted to the emergency room because of shock and loss of consciousness. Electrocardiography and echocardiography revealed myocardial infarction of the inferoposterior wall and cardiac tamponade. However, laboratory data showed mild inflammation without elevation of any cardiac enzymes. Under percutaneous cardiopulmonary support, coronary angiography showed stenosis of only a small posterior descending branch of the right coronary artery. Multislice computed tomography provided a definite diagnosis of free wall rupture of the left ventricle, clearly showing the tear of the inferior wall. After surgical repair and rehabilitation, he returned to a normal life. Small inferior wall infarction rarely causes the blow out type of left ventricular free wall rupture. Multislice computed tomography is a fast and noninvasive tool for the detection of ventricular rupture as well as acute dissection of ascending aorta, both of which may result in cardiac tamponade and may not be visualized by echocardiography.

[Sole guardian's death as a cause of his handicapped mother's death--a case report]

Finding more than one body in the place of residence brings suspicion of poisoning or action of a third party. The authors present a case of two bodies--a handicapped mother and her son--found in their own house. The son was last seen by their neighbours three days before the bodies were revealed. There was a stove in the house which was cold with no signs of penetration. No indication of a third party action was found on the corpses. The autopsy on the son revealed a heart attack with subsequent rupture and tamponade which resulted in death. The cause of the mother's death was assumed to be total starvation of the handicapped person deprived of care. In the presented case autopsy findings contributed to the assessment of the factual cause and sequence of the deaths.

Incomplete myocardial rupture following inferior myocardial infarction: a case report

In an era of early and invasive therapeutic approaches, myocardial rupture has become an uncommon complication of myocardial infarction. While septal wall rupture most often leads to devastating haemodynamic consequences, free wall rupture is usually fatal. We report a case of a 48-year-old man in whom an incomplete myocardial rupture located in the inferior part of the interventricular septum was promptly detected during the acute phase of an inferior myocardial infarction treated by early percutaneous coronary angioplasty. A conservative rather than a surgical approach was decided with a favourable short-term outcome.

Late left ventricular pseudoaneurysm formation following subacute myocardial infarction

We describe a patient with a subacute inferior myocardial infarction who developed a pseudo-aneurysm more than 18 days after the acute event. This is an unusual case with three different complications of a myocardial infarction: Firstly, ventricular rupture is usually the result following transmural myocardial infarction without reperfusion. However, coronary angiography confirmed reperfusion after late thrombolysis in this patient. The subacute rupture could potentially be caused or aggravated by the late thrombolysis. Secondly, this patient developed a mural apical thrombus in a non-infarcted region. It seems most likely that the new infarct caused a low flow state which enhanced thrombus formation. Against expectations, this developed at the apex rather than the site of the recent inferior wall myocardial infarction. Thirdly, we documented the development of a pseudo-aneurysm more than 18 days after the myocardial infarction. This complication is rarely seen at this stage after a myocardial infarction, as most pseudo-aneurysms are formed within 7 days after a myocardial infarction. We have beautifully visualised the apical thrombus and pseudo-aneurysm with echocardiography. This report shows that serial echocardiography is a very useful tool in evaluating the patient's clinical and cardiac status in the period after a myocardial infarction.

Sutureless off-pump repair of post-infarction left ventricular free wall rupture

Left ventricular free wall rupture after myocardial infarction has a high mortality. Suturing techniques of repair may be technically difficult and require cardiopulmonary bypass. We report a case of left ventricular rupture in a 47 year old man managed off pump employing a sutureless technique with Gelatine-Resorcin-Formalin glue and bovine pericardial patches.

Dissecting intramyocardial hematoma masquerading as a pseudoaneurysm of left ventricular free wall: An unusual case of myocardial rupture

This report presents a case of left ventricular intramyocardial dissection masquerading as a ventricular pseudoaneurysm. Only serial echocardiograms could lead to the correct diagnosis, and left ventricular angiography could appropriately direct further testing and treatment.

Endocavitary patch repair for a left ventricular pseudoaneurysm: an alternative approach

We present a case of postinfarction posterolateral left ventricular wall pseudoaneurysm with severe mitral regurgitation and poor left ventricular function. The patient had New York Heart Association (NYHA) class IV heart failure at the time of surgery, which was performed on an emergency basis. The surgical approach included coronary revascularization, surgical posterior mitral leaflet detachment with patch closure of the pseudoaneurysm neck from inside of the left ventricular cavity followed by mitral valve reconstruction, and subsequent implantation of a mitral annuloplasty ring.

[A patient with heart failure and a new murmur: not always a valvular problem]

A 78-year-old man presented with dyspnoea and a 57-year-old with chest pain. Both had a history of coronary atherosclerosis and were now found to have a cardiac murmur. They proved to have a ventricular septal rupture (VSR) that had not been recognized as such. In the older man, the myocardial infarction that caused the VSR had initially not been recognized and in both men the clinical course was erroneously attributed to heart failure caused by myocardial infarction alone. Both underwent surgical correction of the VSR; the older man died due to postoperative intestinal necrosis, the younger man recovered. Patients with a high cardiac-risk profile, atypical chest pain, symptoms ofdyspnoea and a new specific murmur should be suspected of having a VSR. Early recognition and treatment of VSR may reduce mortality significantly.

Left ventricular true aneurysm with pseudoaneurysm detected five years and nine months following repair for oozing type free wall rupture

A case of true aneurysm of the left ventricle associated with pseudoaneurysm was treated surgically. The condition was detected five years and nine months following repair of an oozing type left ventricular free wall rupture due to myocardial infarction. Over this period, chest radiographs showed gradual cardiomegaly with prominence of the left fourth arch.

Contained myocardial rupture: a variant linking complete and incomplete rupture

Myocardial rupture is an uncommon complication of myocardial infarction, often with devastating haemodynamic consequences. Although rupture is usually fatal, when patients do survive, the majority present with a pseudoaneurysm in which the rupture is sealed by a haematoma on the epicardial surface of the heart. Cases in which all myocardial layers are dissected except the epicardium or visceral pericardium have been included under this subheading. The authors describe such a case and suggest the pathological description of a "contained myocardial rupture". This link between complete and incomplete myocardial rupture may allow a more conservative management approach to be pursued.

Trends in the incidence of the free wall cardiac rupture in acute myocardial infarction. observational study: experience of a single center

PURPOSE

Free wall cardiac rupture (CR) is one of the most common cause of in-hospital death in acute myocardial infarction (AMI). The early diagnosis of CR and selection of the patients predisposed to CR become an important clinical tool.

AIM

assessing the occurrence of CR in patients with AMI, to determine the factors which could help to identify the patients threatened with CR.

MATERIAL AND METHODS

2320 consecutive patients with AMI. CR was proved by autopsy or by echocardiography performed during cardio-pulmonary resuscitation (CPR).

RESULTS

In-hospital mortality was 11% (254 patients). 50 patients (2%) died from CR. CR was the cause of 20% of total in-hospital death. Patients with CR were older than survivors (72 vs 60 years, p<0.0001). Women prevailed in CR group: (62% in CR group vs 27% in the survivors, p<0.01). 29% of patients were treated with thrombolytics (Th+). Out of 58 patients from Th (+) group who died, 17 (29.31%) died because of CR. CR occurred in 33 (16.8%) patients out of 196 died in Th (-) group. In the logistic regression analysis only age and sex remained as predictors of CR. 16 patients died from CR during first 24 h from admission (ECR). In 34 patients CR occurred >24 h (LCR). In ECR group were no prevalence of women, while in LCR women constituted 68%. In ECR group all but one patient had no previous history of MI (p=0.06). Frequency of thrombolythic therapy was equal.

CONCLUSIONS

Advanced age patients, particularly women with first AMI are at risk of CR. Decision of thrombolytic treatment in this group of patients must be very cautious.

[Rupture of interventricular septum as consequence of diaphragmatic heart infarct]

Patient, with massive heart attack of the hart's lower wall which happened six months ago, and consequent rupture of the ventricular septum, 1.2 cm of size, next to the left to right shunt, and development of aneurisms at the place of heart attack (4.2 cm x 2.9 cm), is admitted in our Clinic. Weakening signs of the right heart are present with retention of the liquid, edemas and ascites. After a long preoperative preparation graft on CX is being performed, reconstruction of aneurisms of the left verticle, and VSD being reconstructed with Dacron's patch. Postoperative flow is extended with occurrence of profusely diarrhea and existence of a smaller pericardial effusion, but status of the patient is improving, and he is being dismissed home in a satisfactory general condition.

Fulminant liver failure: an indicator of silent myocardial rupture

A 56 year old man presented with an atypical chest infection. Remote inferoposterior myocardial infarction was noted on electrocardiography and transthoracic echocardiography. Hepatic failure developed with sudden gross elevation of liver aminotransferases and coagulopathy. No primary hepatic cause could be identified. Subsequent right heart failure led to transoesophageal echocardiography that revealed a large inoperable ventricular septal defect. Histopathological data showed ischaemic hepatitis and reinfarction of the inferoposterior myocardial wall. Acute cardiac events may be silent and precipitate misleading severe hepatic dysfunction.

Coronary Blood Flow Assessment After Successful Angioplasty for Acute Myocardial Infarction Predicts the Risk of Long-Term Cardiac Events

Background— Analysis of coronary flow velocity (CFV) in the recanalized infarct-related coronary artery (IRA) with a Doppler guidewire is useful for predicting recovery of regional left ventricular function, in-hospital complications, and survival. We postulated that the CFV pattern after IRA reperfusion for acute myocardial infarction (AMI) would predict long-term adverse cardiac events.

Methods and Results— Sixty-eight consecutive patients with a first AMI underwent CFV measurement with a Doppler guidewire after successful reopening of the IRA by coronary angioplasty. At the end of follow-up, 3.8±1.7 years after AMI, 44 of the 65 surviving patients (67.7%) were free of long-term cardiac events. Univariate analysis showed that the following factors were predictive of an end point combining cardiac death, recurrent MI, and congestive heart failure: hypertension, age ≥65 years, time from onset of chest pain to PTCA ≥6 hours, peak creatine kinase >4000 IU/L, ejection fraction ≤50%, proximal left anterior descending artery occlusion, resting average peak velocity ≤10 cm/s, average systolic peak velocity ≤5 cm/s, a rapid diastolic deceleration time (≤600 ms), and early retrograde systolic flow. In the final multivariate model, only age ≥65 years (OR, 3.6; 95% CI, 1.1 to 11.8; P =0.03), time to PTCA ≥6 hours (OR, 2.9; 95% CI, 1.0 to 8.3; P =0.04), and a rapid diastolic deceleration time (OR, 5.4; 95% CI, 1.5 to 19.3; P =0.01) were independent predictors.

Conclusions— The CFV pattern appears to be an accurate predictor of long-term cardiac events in patients having undergone successful reopening of the IRA after AMI, identifying a subset of at-risk patients.

[Mechanical complications of acute myocardial infarction]

Rupture of the left ventricular myocardium during the course of an acute myocardial infarction may affect the free wall, the interventricular septum, or the papillary muscles. When a rupture occurs, it is referred to as a mechanical complication of acute myocardial infarction. All mechanical complications may lead to cardiogenic shock. However, the location of the rupture can often be suspected clinically. To confirm the diagnosis, echocardiography must be performed. Since the advent of thrombolytic therapy and percutaneous coronary intervention, the incidence of mechanical complications has declined. Even though mortality remains high, their recognition is important since survivors may have an excellent long-term prognosis. The cases convey two main messages: 1) Mechanical complications must be carefully searched for in any patient with an acute coronary syndrome and signs of cardiogenic shock and/or a systolic murmur. 2) Aggressive and timely medical and surgical treatment should be provided even though in a substantial proportion of these patients prognosis may be dismal.

Diverse presentations of cardiac rupture following acute myocardial infarction

BACKGROUND

Cardiac rupture is a rare but ominous complication of myocardial infarction.

OBJECTIVES

To study the clinical presentation, medical course, outcome and echocardiographic predictors of patients with myocardial rupture.

METHODS

We evaluated 15 consecutive patients with cardiac rupture during a 4 year period in our department. The current report explores the presence of potential risk factors, timing, relation to the thrombolysis, coronary interventions and outcome.

RESULTS

The index event in all patients was first ST elevation myocardial infarction. In seven patients rupture occurred in the first 24 hours. Pericardial effusion on admission with a clot was present in three patients. Five patients received thrombolytic therapy. Only three patients underwent coronary angioplasty, but in one case it was performed late and in two patients the culprit artery could not be opened. Six patients reached the operating room, of whom three survived.

CONCLUSIONS

The lack of early mechanical reperfusion in acute myocardial infarction and thrombolytic therapy are risk factors for cardiac rupture. Pericardial effusion on admission and evidence of a clot are echocardiographic indicators of cardiac rupture and should alert the medical team to further assess the possibility of cardiac rupture.