Subacute left ventricle free wall rupture after acute myocardial infarction: awareness of the clinical signs and early use of echocardiography may be life-saving

Cardiac Tamponade Secondary to Hemorrhagic Pericardial Effusion: A Complication of STEMI

Background: Most pericardial effusions that occur in the setting of ST-segment elevation myocardial infarction (STEMI) are small, simple, and without symptomology. However, in its most severe form, pericardial effusion can precipitate cardiac tamponade, and when untreated, can cause abrupt hemodynamic instability. Pericardial effusion may be a manifestation of left ventricular free-wall rupture, hemorrhagic pericarditis, or aortic dissection involving a coronary artery. Case Report: We describe the case of a 65-year-old male who experienced chest pain for several days prior to admission but delayed seeking care because he wished to avoid coronavirus disease 2019 exposure. Upon arrival, he was hemodynamically unstable. Electrocardiogram was consistent with anterior STEMI. Bedside echocardiogram demonstrated a hypertrophic left ventricle with preserved function and a large, complex pericardial effusion with cardiac tamponade physiology. Computed tomography of the chest identified hemopericardium but was unable to delineate etiology. The patient underwent emergent thoracotomy because of persistent shock, and during the surgery, left ventricular free-wall rupture was identified and repaired. Coronary artery bypass grafting to the patient's left anterior descending artery was also performed. The patient remained asymptomatic at 2-year follow-up. Conclusion: The differential for hemodynamic compromise in a patient with STEMI is broad, but quickly distinguishing pump failure from other life-threatening causes of shock is imperative to dictate time-sensitive management decisions. The presence of a hemorrhagic pericardial effusion in the setting of STEMI is a surrogate marker for a severe infarct and can help the bedside physician determine whether a patient will be better served in the catheterization lab for revascularization or in the operating room for surgical repair.

Managing Thrombosis and Hemorrhage in a Man with Myocardial Infarction and Traumatic Hemopericardium with Cardiac Tamponade

A 79-year-old man had an out-of-hospital acute ST-segment-elevation myocardial infarction with cardiac arrest. Cardiopulmonary resuscitation performed by a bystander resulted in traumatic hemopericardium. We discuss the patient's case, highlight the challenges of managing simultaneously life-threatening thrombosis and hemorrhage, and present our conclusions regarding the patient's eventual death.

Pericarditis and Post-cardiac Injury Syndrome as a Sequelae of Acute Myocardial Infarction

PURPOSE OF REVIEW

Pericarditis secondary to acute myocardial infarction (AMI) is known to develop either immediately or after a latent period of few months. Due to varied presentation and timing, its diagnosis and treatment can be challenging. This article reviews underlying mechanisms and the role of cardiac imaging in investigating and managing this condition.

RECENT FINDINGS

Timely diagnosis of pericarditis after AMI is important to prevent potential progression to complicated pericarditis. Clinical suspicion warrants initial investigation with serum inflammatory levels, electrocardiogram, and echocardiography. When findings are inconclusive, cardiac magnetic resonance imaging and computerized tomography can provide additional diagnostic information. Pericarditis after AMI is a treatable condition. Clinicians should maintain a high suspicion in this era of revascularization and develop a strategic plan for timely diagnosis and management.

An unexpected electrocardiogram sign of subacute left ventricular free wall rupture: Its early awareness may be lifesaving

BACKGROUND

Post-infarct left ventricular free wall rupture (LVFWR) is not always an immediately catastrophic complication. The rupture can be subacute, allowing time for diagnosis and intervention. Accordingly, early recognition of the entity may be lifesaving.

METHODS

We present an electrocardiogram (ECG) change pattern in two cases, which was erroneously attributed to ischemia. Two women in their 80s were admitted to our institute after experiencing the sudden onset of chest pain. They were managed as anterior ST-segment elevation myocardial infarction without reperfusion treatment. Unfortunately, they experienced a recurrence of severe chest pain with cardiogenic shock during hospitalisation. The ECG recorded at that time showed a ST-segment re-elevation in infract-related leads.

RESULTS

The two cases were regrettably received a misjudgement of reinfarction at first, and one of the patients even was administrated with tirofiban. Afterwards the diagnosis of subacute LVFWR was made through antemortem echocardiography.

CONCLUSION

New ST-segment elevation (STE) in infarct-associated leads, coupled with recurrence of chest pain and new-onset hypotension, may constitute the premonitory signs of a subacute LVFWR.

Successful emergent repair of a subacute left ventricular free wall rupture after acute inferoposterolateral myocardial infarction

Background

Myocardial rupture is an important and catastrophic complication of acute myocardial infarction. A dramatic form of this complication is a left ventricular free wall rupture (LVFWR).

Case presentation

A 70-year-old man with acute inferoposterolateral myocardial infarction and single-vessel coronary artery disease underwent emergency percutaneous coronary intervention (PCI). The circumflex coronary artery was successfully stented with a drug-eluting stent. Fifty days after PCI the patient experienced progressive fatigue and chest pain with haemodynamic instability. Transthoracic echocardiography showed a covered LVFWR of the lateral wall. The patient underwent successful emergent surgical repair of the LVFWR.

Conclusions

In the current era of swift PCI, mechanical complications of acute myocardial infarction, such as LVFWR, are rare. The consequences, however, are haemodynamic deterioration and imminent death. This rare diagnosis should always be considered when new cardiovascular symptoms or haemodynamic instability develop after myocardial infarction, even beyond one month after the initial event. Timely diagnosis and emergency surgery are required for successful treatment of this devastating complication.

Comparison of distinctive clinical and cardiac magnetic resonance features between ST elevation myocardial infarction patients with incomplete myocardial rupture and those with moderate to severe pericardial effusion

BACKGROUND

Whether patients with incomplete myocardial rupture (IMR) present distinctive clinical and cardiac magnetic resonance features from those with moderate-severe pericardial effusion (⩾10 mm (PE)) remains unknown.

METHODS

We compared the clinical, angiographic and cardiac magnetic resonance characteristics of nine patients with IMR (diagnosed angiographically and/or by cardiac magnetic resonance) with 29 with PE, and also with 38 without IMR or PE with evidence of transmural necrosis (reference group) matched for age, gender and year of admission.

RESULTS

Patients with IMR were younger than those with PE (p<0.001) but the two groups shared a higher rate of admission delay (78% and 41%) than those without IMR/PE (5%, p<0.001) and lower frequency of reperfusion therapy (44%, 55% and 100%, respectively, p<0.001). Thirteen patients with PE (45%) but only one IMR (11%) presented recurrent chest pain. IMR patients tended to present smaller infarct size at cardiac magnetic resonance (p=0.153 and 0.036) and number of segments with ⩾75% necrosis than PE patients and those without IMR/PE (p=0.098 and 0.029, respectively). Ten PE patients presented cardiac tamponade (35%). A control 2D-echocardiogram performed within two years in 71 patients (93%) documented a pseudoaneurysm in one PE and in one IMR patient.

CONCLUSIONS

IMR is generally silent and occurs in younger patients with smaller infarct size than those with PE although both present late and are often untreated with reperfusion therapy. These findings may warrant imaging assessment in ST elevation myocardial infarction patients with delayed admission, particularly in absence of reperfusion, to rule out an IMR.

Post-MI free wall rupture syndrome. Case report, literature review, and new terminology

Common clinical features of subacute rupture left ventricular free wall after acute ST segment elevation myocardial infarction are: (1) recurrent or persistent chest pain; (2) recurrent or persistent ST segment elevation; (3) hypotension. Integrating these signs into a syndrome can increase the clinician's awareness to the fatal complication.

Left ventricular pseudoaneurysm after myocardial infarction detected by cardiac MRI

Left ventricular free wall rupture (LVFWR) is a grave complication of acute myocardial infarction. Acutely, it has an extremely high rate of mortality, especially if undetected. Chronically, there is paucity of data on how to manage the pathology, especially if detected as an incidental finding. We present a unique case of initially undetected LVFWR in a patient who presented with repeated chest pain. Cardiac MRI enabled the diagnosis and localisation of the original site of LVFWR and provided highly relevant volume calculations. Measurement of both absolute and virtual volumes indicated that aneurysm resection, including the original site of rupture, was surgically feasible without reducing postoperative stroke volume.

Successful percutaneous closure of post myocardial infarction left ventricular ruptured pseudoaneurysm after failed surgical repair

Left ventricular pseudoaneurysms occur as a consequence of left ventricular free wall rupture contained by pericardium. This clinical situation is an uncommon but lethal complication of acute myocardial infarction. Surgery usually is the preferred therapeutic option but is associated with significant perioperative risk. We present a case of successful percutaneous closure of left ventricular ruptured pseudoaneurysm post myocardial infarction in a patient who failed two previous surgical repairs. <Learning objective: Recently there has been some published experience regarding percutaneous closure of left ventricle pseudoaneurysm as an alternative to surgical repair in patients at high operative risk. To the best of our knowledge this is the first reported case that demonstrates successful percutaneous closure of ruptured pseudoaneurysm after failed surgical repairs.>.

Adjuvant Role of CT in the Diagnosis of Post-Infarction Left Ventricular Free-Wall Rupture

Left ventricular free wall rupture is usually a catastrophic mechanical complication of myocardial infarction. Risk factors include advanced age, female gender and absence of prior infarction. The vast majority of patients succumb rapidly due to cardiac tamponade and electromechanical dissociation. Expedited and accurate diagnosis can improve the chances of survival. Echocardiography has been advocated as the gold standard for diagnosis, but other imaging modalities can provide valuable information in these patients. We present the case of a patient who presented with cardiogenic shock, in which the definitive diagnosis of a left ventricular free wall rupture was accomplished by CT scan with intravenous contrast.

Cardiac rupture

BACKGROUND

Cardiac rupture is an unusual cause of chest pain and sudden cardiovascular collapse. This diagnosis may be easily forgotten while managing a patient in extremis in the initial minutes of evaluation and resuscitation in the emergency department (ED).

OBJECTIVES

To report the benefit of immediate bedside cardiac ultrasonography in the diagnosis of cardiac rupture and its influence on emergent intervention in the ED.

CASE REPORT

The initial electrocardiogram, performed within 5 min of arrival, of a 65-year old man who presented with 20 min duration of chest pain, showed a biphasic T wave in V1 and inverted T wave in V2, without ST-segment elevation myocardial infarction. Fifteen minutes later, he lost consciousness and was pulseless without a shockable rhythm on the monitor. Chest compressions were started and the patient was intubated. Echocardiography was performed at the bedside by the emergency physician. Cardiac contractility was grossly decreased in both ventricles and a large amount of pericardial fluid was seen. Two attempts at ultrasound-guided pericardiocentesis yielded only a few milliliters of blood. Interruptions in chest compressions were minimized during pericardiocentesis. Before transport of the patient to the operating room for definitive repair, asystole occurred. On the subsequent echocardiogram, heart contractions were absent and a hematoma was seen in the pericardial space. Resuscitation efforts were stopped. An autopsy was not performed per family request.

CONCLUSIONS

Typical ultrasonographic findings of cardiac rupture were present in this patient, who presented in extremis with chest pain. Early bedside echocardiography can be helpful in directing the initial care of critically ill patients.

Contained Left Ventricular Free Wall Rupture following Myocardial Infarction

Rupture of the free wall of the left ventricle occurs in approximately 4% of patients with infarcts and accounts for approximately 20% of the total mortality of patients with myocardial infractions. Relatively few cases are diagnosed before death. Several distinct clinical forms of ventricular free wall rupture have been identified. Sudden rupture with massive hemorrhage into the pericardium is the most common form; in a third of the cases, the course is subacute with slow and sometimes repetitive hemorrhage into the pericardial cavity. Left ventricular pseudoaneurysms generally occur as a consequence of left ventricular free wall rupture covered by a portion of pericardium, in contrast to a true aneurysm, which is formed of myocardial tissue. Here, we report a case of contained left ventricular free wall rupture following myocardial infarction.

Impending myocardial rupture: is an early surgical treatment enough?

A 53-year-old man with a high-risk cardiovascular profile presented to the emergency department for a subacute myocardial infarction with signs and symptoms suggesting impending myocardial rupture. The case seemed to be resolved by an early successful surgical intervention. At 6-month follow-up, after repeated cycles of cardiac rehabilitation, the echocardiography revealed a pseudo-aneurysm of the apex and a left-to-right shunt through an inter-ventricular septum defect. The patient needed a new surgical intervention to repair this unexpected complication.

Acute left ventricular rupture following posterior wall myocardial infarction

Free wall rupture, the most fearful complication of myocardial infarction, mostly attacks anterior walls. Acute rupture is characterized by rapid development of mechanical arrest accompanied with bradyarrhythmia or electromechanical dissociation. The majority of patients succumb to death as the result of cardiac tamponade. Risk factors are advanced age, female gender, the first-time myocardial infarction, hypertension, and ST-segment elevation. We report a rare case of posterior wall myocardial infarction complicated with left ventricular rupture initially presenting with junctional escape rhythm.

Global ST-segment elevation associated with impending cardiac rupture during diagnostic cardiac catheterization

Cardiac rupture is a life-threatening complication during diagnostic cardiac catheterization, however, it rarely occurs nowadays. The present case report describes cardiac rupture during diagnostic cardiac catheterization using a 4F pigtail catheter and a 0.035" flexible guidewire, and global ST-segment elevation associated with impending cardiac rupture.

Left ventricular free wall rupture subsequent to early myocardial reinfarction after successful percutaneous transluminal coronary angiography

Left ventricular free wall rupture is a rare complication of acute myocardial infarction. Scarcely has a cardiac rupture subsequent to early reinfarction been reported. A left ventricular free wall rupture subsequent to reinfarction after successful percutaneous transluminal coronary angiography in a 78-year-old female is herein described.

Contained rupture of left ventricular false aneurysm after acute myocardial infarction secondary to left anterior descending artery embolism

Left ventricular free wall rupture is a rare complication of acute myocardial infarction and accounts for a significant number of fatalities. Pseudoaneurysm is a variety of left ventricular rupture whereby the pericardium seals the defect, forming the wall of the pseudoaneurysm. The diagnosis is usually confirmed with echocardiography, and emergent surgical repair is required in suspected impending rupture. The present report describes the case of a 58-year-old woman who presented with a myocardial infarction due to distal left anterior descending artery occlusion, complicated by ventricular pseudoaneurysm with impending rupture. The patient had an otherwise normal coronary tree.