Pseudoaneurysm following lateral wall myocardial infarction

Pseudoaneursym (PA) formation of left ventricle (LV) following acute myocardial infarction (AMI) is uncommon and is usually believed to be associated with a grave prognosis. We describe a case of 55 year old male patient presented with AMI and heart failure with a systolic murmur later diagnosed to have PA of the lateral wall of LV on echocardiography (transthoracic and transesophageal, TTE andTEE). Cardiac MRI and coronary angiogram (CAG) were performed. CAG showed 60% lesion at origin of major obtuse marginal artery (OM1). The patientwas advised surgical treatment, but he refused and took discharge against medical advice on 27th dayof admission on stable condition.

Cardiac rupture in acute myocardial infarction with ST segment elevation. Clinical course and prognosis

INTRODUCTION

Cardiac rupture (CR), involving left ventricular free wall, interventricular septum or papillary muscles, accounts for 15% of all deaths in the acute phase of myocardial infarction (MI). After cardiac arrhythmias and cardiogenic shock, CR is the third most common cause of death in acute MI. In spite of progress in the treatment of MI, mortality due to CR did not change in recent years.Aim. To assess the incidence, clinical course and outcome in patients with acute MI complicated by CR who were treated in our centre.

METHODS

The study group consisted of 697 consecutive patients who were hospitalised due to acute MI with ST segment elevation (STEMI). The in-hospital and three-month follow-up data were analysed in 27 (3.9%) patients who developed CR. In 20 patients CR occurred in the left ventricular free wall, in 5 interventricular septum, in one both of these structures, and in one papillary muscle. The diagnosis of CR was based on clinical presentation and echocardiography.

RESULTS

The overall mortality in 697 patients with STEMI was 10.5%. Mortality rate in patients with CR was 55.6% (15 patients) which accounted for 20.5% of all deaths. Nine patients with CR underwent cardiac surgery whereas 18 were treated conservatively. Two (22.2%) patients from the former group and 13 (72.2%) patients from the latter group died.

CONCLUSIONS

1. Mortality due to CR was increased in patients who were treated conservatively, who received thrombolysis and those who were females. 2. Rapid and accurate diagnosis, proper correction of hemodynamical disturbances and timely introduction of cardiac surgery improve prognosis in patients with CR complicating STEMI.

[Case description of the abnormally big pseudoaneurysm in a patient after myocardial infarction]

Authors present a case of a 72 years old woman with an abnormally big left ventricular pseudoaneurysm as a consequence of a rupture of the left ventricular wall during myocardial infarction. Pseudoaneurysm threatens its carrier with both sudden death as a result of the rupture and a progressing heart failure. The patient mentioned has undergone an infero-lateral myocardial infarction complicated with beginning cardiogenic shock in July 2001. Based on coronarography examination which proved only peripheral stenoses in coronary bed a conservative procedure was indicated. In June 2002 the patient was admitted to a hospital for progressive dyspnoea, nonspecific chest and epigastric pain, and dyspeptic complaints. Transtoracal echocardiography examination proved a large pseudoaneurysm coming from periapical bottom wall of the left ventricle. Diagnosis was further confirmed and specified by ventriculography and the patient was indicated for surgery. Authors present a range of clinical signs of pseudoaneurysm, an approach to an examination, differential diagnostics and treatment procedure in patients with this unusual complication.

[Papillary muscle rupture]

Papillary muscle rupture (PMR) is a rare, but catastrophic mechanical complication of acute myocardial infarction (AMI). Patients with PMR present in acute pulmonary edema and commonly in cardiogenic shock. The absence of new heart murmur after AMI dose not exclude the diagnosis. To diagnose PMR accurately, transesophageal echocardiography is the most useful and essential, coronary angiography is also necessary for appropriate surgical treatment. Based on these results of diagnostic procedure, combined myocardial revascularization and mitral operation should be performed without delay. Although mitral valve repair has the effects of improving left ventricular function, repairing could be undertaken successfully in limited cases, such as ruptured muscle tissue is not friable. If repair is technically more challenging, mitral valve replacement should not be hesitated. Postoperative early and late survival may relate to surgical correction of coronary artery revascularization, especially in multivessel disease, concomitant coronary artery bypass grafting is benefit theoretically and should be performed.

Cardiac rupture complicating myocardial infarction

Rupture of the ventricular free wall is a leading cause of death in patients with acute myocardial infarction (MI). There are a number of risk indicators that are associated with cardiac rupture, such as female gender, old age, hypertension, and first MI. Typical symptoms of cardiac rupture are recurrent or persistent chest pain, syncope, and distension of jugular veins. Electrocardiographic signs may include sinus tachycardia, new Q-waves in 2 or more leads, persistent or recurrent ST segment elevation, deviation of expected evolutionary T-wave pattern, and electromechanical dissociation in end-stage cases. Once patients at risk have been identified using clinical symptoms and electrocardiographic signs, a fast and sensitive diagnostic test to confirm cardiac rupture is transthoracic echocardiography (TTE). New insights in the etiology of subacute myocardial rupture suggests that defective cardiac remodeling may predispose the heart for rupture. The matrix metalloproteinase (MMP) system has been shown to play an important role in cardiac extracellular matrix (ECM) remodeling and cardiac rupture. Current therapy of cardiac rupture consists mainly of surgery, and conservative management with hemodynamic monitoring, prolonged bed rest, beta-blockers, and angiotensin-converting enzyme (ACE) inhibitors in selected cases.

Acute myocardial infarction after radiofrequency catheter ablation of typical atrial flutter: histopathological findings and etiopathogenetic hypothesis

The right atrial inferior cavotricuspid isthmus represents the targeting site for radiofrequency (RF) current application during ablation treatment of typical atrial flutter. Despite the vicinity of the right coronary artery (RCA) to the RF application site and the long energy exposure needed to achieve electrophysiological success, reports about direct thermal damage of the coronary vessel during ablation of the cavotricuspid isthmus are rare and anecdotal. The present is the first case report describing the cardiac macroscopic and histological examination in a patient who died of cardiac rupture, as a complication of a myocardial infarction occurring after a standard procedure of RF ablation of typical atrial flutter. In consideration of the proximity we found between the RF energy-dependent tissue damage and the RCA, thermal-related damage of RCA during ablation of typical atrial flutter should always be considered as a potentially harmful risk of the procedure.

“Sandwich Technique” via Right Ventricle Incision to Repair Postinfarction Ventricular Septal Defect

We describe two cases where postinfarction ventricular septal defect (VSD) was treated with a new technique. Application of direct ultrasonography to the right ventricular (RV) wall enables the surgeon to visualize the region and perform appropriate incision into the right ventricle and trabecula resection. The VSD is sealed with gelatin-resorcin-formal (GRF) glue between two patches, one placed on the left ventricular side and the other on the right ventricular side. RV incision provides easy bleeding control and the "sandwich technique" using two patches and GRF sealing provides geometric preservation of the left ventricular shape and prevents residual shunt.

Transcatheter closure of a ruptured ventricular septum following inferior myocardial infarction and cardiogenic shock

Elective transcatheter closure of congenital septal defects has emerged as a valuable method, but the clinical experience on occlusion of ventricular septal rupture after myocardial infarction is very limited. We report a case of fatal outcome in a patient with inferior myocardial infarction and cardiogenic shock despite technically successful transcatheter closure of a large complex ventricular septal defect.

Ventricular free wall rupture following acute myocardial infarction

SUMMARY

Ventricular free wall rupture remains a dreaded complication of acute myocardial infarction. A dramatic fatal presentation is not universal and if recognized early, especially in its sub-acute form, a therapeutic intervention may be lifesaving. Changing trends in its natural history and the previously described pathological subtypes have emerged since the advent of thrombolysis. Although frequently unpredictable, certain clinical, echocardiographic and electrocardiographic signs should suggest the diagnosis. Moreover, knowledge of predisposing risk factors and a high index of suspicion are helpful in early recognition of this complication. In recent years, several different therapeutic approaches have been described including percutaneous seals and surgical mechanical closure of ventricular free wall rupture. In this review, we sought to highlight established and debatable aspects of this pathology to hopefully enhance prompt diagnosis and treatment by all clinicians caring for patients suffering acute myocardial infarction.

Left ventricular free wall rupture after reperfusion therapy for acute myocardial infarction

We evaluated the clinical significance of angiographic indexes and pericardial involvement in predicting increased risk of free wall rupture after reperfusion therapy and found that Thrombolysis In Myocardial Infarction (TIMI) <3 flow grade after reperfusion therapy was a significant variable related to the free wall rupture. Moreover, pericardial rub was found to be a significant variable related to TIMI <3 grade flow after reperfusion, which indicates that detection of pericardial rub is one of the clinical signs that predicts inadequate anterograde flow of the infarct-related artery after reperfusion and hence, higher risk for free wall rupture.

Transatrial approach of acquired posterior ventricular septal rupture and double orifice technique in tricuspid valve repair

We present a successful transatrial repair of ventricular septal rupture and tricuspid valve reconstruction, using the "edge-to-edge" technique, as a serious complication of a posterior myocardial infarction in an 83-year-old woman.

Mechanical complications after myocardial infarction reliably predicted using C-reactive protein levels and lymphocytopenia

We assessed the accuracy of C-reactive protein (CRP) levels and lymphocyte counts to predict a mechanical complication (MC) after myocardial infarction (MI). Within 10 years, we identified 36 patients with 39 echocardiographically confirmed MC within 30 days of MI: ventricular septal defect (17 cases), papillary muscle rupture (10 cases), and left ventricular free wall rupture (12 cases). They were compared to 41 controls with an uncomplicated hospital course after MI. Peak CRP levels and minimum relative lymphocyte counts obtained within 96 h of the acute MI (AMI) and before diagnosis of the complication were compared with clinical parameters. Prior to the MC, peak CRP levels were significantly higher (p < 0.001) and relative lymphocyte counts lower (p < 0.001) than in controls while creatine kinase levels did not differ (p = nonsignificant). Using multivariate logistic regression, the following score was identified to have excellent prognostic significance for MC: CRP (mg/l) - 10 x Lyc (%). The area under the receiver-operating characteristic curve was 0.90 +/- 0.05 (p < 0.001). Combined use of CRP levels and relative lymphocyte counts may be helpful in accurately predicting an MC after AMI and should therefore be routinely assessed.

Sutureless patch repair of post-myocardial infarction left ventricular rupture

Ventricular rupture following myocardial infarction is a serious clinical problem with a high mortality. A 60-year-old man with left ventricular rupture and cardiac tamponade following myocardial infarction was managed successfully by emergency surgery. An onlay patch of Teflon held in place by an adhesive without any sutures was used to repair the ruptured myocardium.

[Intramyocardial dissecting haematoma: an unusual form of cardiac rupture]

The intramyocardial dissecting haematoma is an unusual rupture of the left ventricular wall, complicating acute myocardial infarction. The mechanism is an hemorrhagic dissection among the spiral myocardial fibres creating a neocavitation limited by the myocardium. It appears in 9% of left ventricular wall ruptures, complicating acute myocardial infarction. Diagnosis is often difficult and in most of the cases it is post-mortem. We present the case report of a 69 year old patient who suffered a posterolateral acute myocardial infarction treated with primary PTCA/Stent plus AAS, clopidogrel, unfractioned heparin bolus and GP IIb- IIIa inhibitors. In the following few hours he suffered this unusual form of cardiac rupture that took him into cardiogenic shock and finally led to his death. The pathophysiology, diagnosis and management of this lethal complication of acute myocardial infarction (90% mortality in the medically treated group) which is only effectively treated by surgery are also reviewed.

Cardiopulmonary resuscitation does not cause left ventricular rupture of the heart with acute myocardial infarction: a pathological analysis of 77 autopsy cases

Cardiac rupture during acute myocardial infarction (AMI) is one of the most frequent causes of sudden cardiac death. However, some reports have indicated the possibility that the cardiac rupture during AMI may occur by external cardiac massage. We pathologically examined the hearts of 77 patients who died suddenly due to ventricular free wall rupture during AMI (51 men and 26 women; aged 47-94 years; mean age: 69.9 years). We divided the cases into two groups, 44 cases with and 33 cases without cardiopulmonary resuscitation (CPR), and compared the two groups with respect to 12 pathological items. There were no statistical differences in any of the investigated items between the two groups (P>0.05). In addition, mural thrombi were identified along the rupture tract in all cases. Moreover, they were more matured at the subendocardial zone than at the subepicardial or middle zone, irrespective of the groups. From the pathological findings, we concluded that the rupture of the left ventricle during AMI originates from the subendocardial region and precedes the external cardiac massage. Our present study strongly suggests that CPR does not cause the left ventricular rupture of the heart during AMI.

Cardiac pseudoaneurysm coupled with a rupture of the papillary muscle complicating myocardial infarction

As a complication of myocardial infarction, dual rupture of the left ventricular myocardium and the papillary muscle is a rare condition. In such a case, the heart is predisposed to reduced output because of unloading of the ventricle during systole, resulting in the patient being in danger of deteriorating into a severe state or dying suddenly from cardiogenic shock. We report a rescued case of a 65-year-old woman, who had cardiogenic shock due to left ventricular pseudoaneurysm, coupled with partial rupture of the posteromedial papillary muscle three weeks after posterior myocardial infarction. Emergent left ventriculography revealed a large aneurysmal cavity and regurgitation towards the left atrium. The patient underwent emergent aneurysmectomy with mitral valve replacement.

Rupture of both papillary muscles after acute myocardial infarction: a case report

The authors report a case of transthoracic echocardiographic left ventriculography and surgical pathology findings of a patient with rupture of both papillary muscles after acute myocardial infarction.

Rupture of the anterolateral papillary muscle caused by a single diagonal branch obstruction

This report presents the first case of anterolateral papillary muscle rupture caused by a diagonal branch occlusion only. Although the patient was in shock on admission, he was successfully treated by emergency surgery after hemodynamic stabilization by a percutaneous cardiopulmonary support system. This case implies that the anterolateral papillary muscle has a single blood supply and that it can rupture by an occlusion of only one diagonal branch even after balloon angioplasty.

Direct visualization of left ventricular free wall rupture by levocardiography

Two cases of left ventricular free wall rupture and one case of combined left ventricular free wall and ventricular septal rupture are described where ventriculography played a key role in diagnosis. In all three cases of patients with acute myocardial infarction, identification and localization of the defect was made by angiography. This report illustrates the safety and feasibility of ventriculography in patients with suspected cardiac rupture.