Left ventricular free wall rupture caused by myocardial ischemia without treatable atherosclerotic coronary disease: a case series

BACKGROUND

The clinical presentation of left ventricular free wall rupture (LVFWR) varies ranging from uneventful condition to congestive heart failure. Here we report two cases of LVFWR with different clinical presentation and notable outcome. A 53-year-old male presenting emergently with signs of myocardial infarction received immediate coronary angiography and thoracic CT-scan showing occlusion of the first marginal coronary branch without possibility of revascularization and minimal pericardial extravasation. Under ICU surveillance, LVFWR occurred 24 h later and was treated by pericardiocentesis and ECMO support followed by immediate uncomplicated surgical repair. Postoperative therapy-refractory vasoplegia and electromechanical dissociation caused fulminant deterioration and the early death of the patient. The second case is a 76-year old male brought to the emergency room after sudden syncope, clinical sings of pericardial tamponade and suspicion of a type A acute aortic dissection. Immediate CT-angiography excluded aortic dissection and revealed massive pericardial effusion and a hypoperfused myocardial area on the territory of the first marginal branch. Immediate sternotomy under mechanical resuscitation enabled removal of the massive intrapericardial clot and revealed LVFWR. After an uncomplicated surgical repair, an uneventful postoperative course, the patient was discharged with sinus rhythm and good biventricular function. One year after the operation, he is living at home, symptom free.

DISCUSSION

Whereas the younger patient, who was clinically stable at hospital admission received delayed surgery and did not survive treatment, the older patient, clinically unstable at presentation, went into immediate surgery and had a flawless postoperative course. Thus, early surgical repair of LVFWR leads to best outcome and treating LVFWR as a high emergency regardless of the symptoms improve survival.

Severe tricuspid regurgitation with chordae tendinae rupture in CABG surgery

A 58-year-old male patient was admitted with chest pain and was diagnosed with coronary heart disease. He was scheduled for coronary artery bypass grafting (CABG) under cardiopulmonary bypass (CPB). Intraoperative real-time transesophageal echocardiography (TEE) showed that the tricuspid valves were well-aligned and subtle regurgitation. Real-time TEE after separation from CPB showed severe tricuspid regurgitation and prolapsed chordae tendineae. The tricuspid chordae tendineae rupture due to a right atrial venous return cannula. The use of negative pressure to improve venous drainage during CPB may result in the tricuspid valve being adsorbed to the cannula, increasing the likelihood of injury to the tricuspid valve.

Cardiac rupture in acute myocardial infarction: a cardiac magnetic resonance study

AIMS

We assessed the feasibility of cardiac magnetic resonance (CMR) and the role of myocardial strain in the diagnostic work-up of patients with acute myocardial infarction (AMI) and a clinical suspicion of cardiac rupture (CR).

METHODS AND RESULTS

Consecutive patients with AMI complicated by CR who underwent CMR were enrolled. Traditional and strain CMR findings were evaluated; new parameters indicating the relative wall stress between AMI and adjacent segments, named wall stress index (WSI) and WSI ratio, were analysed. A group of patients admitted for AMI without CR served as control. 19 patients (63% male, median age 73 years) met the inclusion criteria. Microvascular obstruction (MVO, P = 0.001) and pericardial enhancement (P < 0.001) were strongly associated with CR. Patients with clinical CR confirmed by CMR exhibited more frequently an intramyocardial haemorrhage than controls (P = 0.003). Patients with CR had lower 2D and 3D global radial strain (GRS) and global circumferential strain (in 2D mode P < 0.001; in 3D mode P = 0.001), as well as 3D global longitudinal strain (P < 0.001), than controls. The 2D circumferential WSI (P = 0.010), as well as the 2D and 3D circumferential (respectively, P < 0.001 and P = 0.042) and radial WSI ratio (respectively, P < 0.001 and P: 0.007), were higher in CR patients than controls.

CONCLUSION

CMR is a safe and useful imaging tool to achieve the definite diagnosis of CR and an accurate visualization of tissue abnormalities associated with CR. Strain analysis parameters can give insights into the pathophysiology of CR and may help to identify those patients with sub-acute CR.

Porphyromonas gingivalis, a periodontal pathogen, impairs post-infarcted myocardium by inhibiting autophagosome-lysosome fusion

While several previous studies have indicated the link between periodontal disease (PD) and myocardial infarction (MI), the underlying mechanisms remain unclear. Autophagy, a cellular quality control process that is activated in several diseases, including heart failure, can be suppressed by Porphyromonas gingivalis (P.g.). However, it is uncertain whether autophagy impairment by periodontal pathogens stimulates the development of cardiac dysfunction after MI. Thus, this study aimed to investigate the relationship between PD and the development of MI while focusing on the role of autophagy. Neonatal rat cardiomyocytes (NRCMs) and MI model mice were inoculated with wild-type P.g. or gingipain-deficient P.g. to assess the effect of autophagy inhibition by P.g. Wild-type P.g.-inoculated NRCMs had lower cell viability than those inoculated with gingipain-deficient P.g. This study also revealed that gingipains can cleave vesicle-associated membrane protein 8 (VAMP8), a protein involved in lysosomal sensitive factor attachment protein receptors (SNAREs), at the 47th lysine residue, thereby inhibiting autophagy. Wild-type P.g.-inoculated MI model mice were more susceptible to cardiac rupture, with lower survival rates and autophagy activity than gingipain-deficient P.g.-inoculated MI model mice. After inoculating genetically modified MI model mice (VAMP8-K47A) with wild-type P.g., they exhibited significantly increased autophagy activation compared with the MI model mice inoculated with wild-type P.g., which suppressed cardiac rupture and enhanced overall survival rates. These findings suggest that gingipains, which are virulence factors of P.g., impair the infarcted myocardium by cleaving VAMP8 and disrupting autophagy. This study confirms the strong association between PD and MI and provides new insights into the potential role of autophagy in this relationship.

Successful Percutaneous Intervention of Contained Coronary Artery Rupture: The Role of Intracoronary Imaging

A 66-year-old male presented with ST-segment-elevation myocardial infarction. Percutaneous coronary intervention (PCI) of the culprit right coronary artery lesion was performed, during which a small wire-related perforation was noted. The perforation was no longer visible post procedure and we opted for conservative management. One month later, coronary angiography before intervention of the left anterior descending and circumflex lesions revealed a focal dilation at the site of the earlier wire perforation. Further imaging with intravascular ultrasound and optical coherence tomography visualized the defect and guided treatment options.

Left Ventricular Free-Wall Rupture After Late-Admission STEMI

This case illustrates a rare but catastrophic complication of acute myocardial infarction, ie, acute rupture of the left ventricular free wall. The majority of patients have hemodynamic impairment on arrival, and a high level of suspicion is needed. Point-of-care echocardiogram is valuable for prompt diagnosis. Management is very challenging and is based on fluid infusion, inotropic support, and pericardiocentesis. Emergency coronary artery bypass grafting and ventricular wall suture may be the only definitive treatment available, although in the majority of cases timely treatment is not possible.

Acute Left Ventricle Free-Wall Rupture Post Primary PCI: In Vivo Imaging

A 69-year-old male was referred to our cath lab for primary percutaneous coronary intervention due to acute anterior ST-segment elevation myocardial infarction. Left coronary angiography revealed acute occlusion of the proximal left anterior descending artery. After several additional diagnostic procedures and implantation of a drug-eluting stent, an abrupt clinical deterioration manifested with sudden hypotension. There was evidence of cardiac tamponade, and the constant supply of blood from the pericardium along with the development of cardiogenic shock state led us to suspect cardiac laceration. This imaging series illustrates a heart team operating in vivo on a rare acute myocardial infarction mechanical complication, which occurred soon after primary percutaneous coronary intervention.

[Coronary Artery Bypass Grafting to the Left Anterior Descending Artery via Anterior Minithoracotomy after Surgery for Acute Papillary Muscle Rupture;Report of a Case]

We presented a case with chronic occlusion of the left anterior descending artery(LAD) after mitral valve replacement (MVR). An 80-year-old man was transferred to our hospital with a diagnosis of acute myocardial infarction. Before coronary angiography, the patient suddenly fell in a state of cardiogenic shock. Echocardiography revealed acute mitral regurgitation due to anterior papillary muscle rupture. Although emergency MVR was performed, introduction of percutaneous cardiopulmonary support (PCPS) and intraaortic balloon pumping ( IABP) was needed to come off cardiopulmonary bypass. Postoperative coronary angiography revealed chronic occlusion of LAD. The left internal thoracic artery was anastomosed to LAD via anterior minithracotomy to avoid median re-sternotomy. The postoperative course was uneventful and the cardiac function improved.

[Successful Repair of a Blow-out Type Left Ventricular Free Wall Rupture after Acute Myocardial Infarction Using a Viscous Diisocyanate Prepolymer]

We report our experience with blow-out type left ventricular free wall rupture after acute myocardial infarction, treated by a sutureless technique using Hydrofit (a viscous diisocyanate prepolymer). A 70-year-old woman suddenly experienced cardiopulmonary arrest during gastrointestinal endoscopic examination. Computed tomography revealed cardiac tamponade, loss of contrast in the posterolateral wall of the left ventricle and contrast medium leakage into the pericardial cavity from the lateral wall of the left ventricle. Under cardiopulmonary resuscitation, the patient was transferred to our hospital. Percutaneous cardiopulmonary support was initiated in the operating room, and median sternotomy was immediately performed. The myocardial tear and necrotic area were sealed with Hydrofit and further covered with BioGlue and TachoSil under cardioplegic heart arrest. Hemostasis was completely achieved, and cardiopulmonary bypass (CPB) was discontinued under intraaortic balloon pumping (IABP) support. At 5 years after surgery, echocardiography showed no pseudoaneurysm formation. This sutureless repair technique using Hydrofit may be useful for a selected case of blow-out type left ventricular free wall rupture.

[Noncoronary Necrosis With Myocardial Rupture in a Young Woman]

The article presents a clinical case of development of noncoronary myocardial necrosis with cardiac rupture in a young woman at a background of severe stress.

[Risk factors of cardiac rupture in patients with acute myocardial infarction]

Objective: To analyze the risk factors of cardiac rupture in patients with acute myocardial infarction. Methods: Clinical data were analyzed from 10 284 acute myocardial infarction patients admitted to Beijing Anzhen Hospital from January 2012 to March 2015. Cardiac rupture occurred in 81 patients, including 67 patients of acute left ventricular free wall rupture and 14 patients of ventricular septal defect, were retrospectively analyzed. Binary logistics regression analysis was performed to analyze the risk factors of cardiac rupture. Results: Incidence of cardiac rupture was significantly higher in patients with ST-segment elevation myocardial infarction than in patients with non-ST-segment elevation myocardial infarction (1.5%(70/4 724) vs. 0.2%(11/5 560), P<0.01). Binary logistic regression analysis showed that age (OR=0.827, 95%CI 0.726-0.941, P<0.01), recurrent myocardial infarction during hospital(OR=0.001, 95%CI 0.000-0.418, P<0.05), systolic blood pressure(OR=1.114, 95%CI 1.029-1.206, P<0.01), left anterior descending artery lesion (OR=0.003, 95%CI 0.000-0.334, P<0.05), lower hemoglobin(OR=1.129, 95%CI 1.051-1.212, P<0.01), serum total protein (OR=1.453, 95%CI 1.070-1.971, P<0.05), and serum magnesium level (OR=0.000, 95%CI 0.000-0.001, P<0.01) were associated with cardiac rupture. Conclusion: Older age, recurrent myocardial infarction, lower systolic blood pressure, left anterior descending artery lesion, lower serum hemoglobin, lower serum total protein, and higher serum magnesium level are risk factors of cardiac rupture and these factors should be carefully managed to prevent the occurrence of cardiac rupture.

Temporal changes in matrix metalloproteinase expression and inflammatory response associated with cardiac rupture after myocardial infarction in mice

We previously found that male mice with myocardial infarction (MI) had a high rate of cardiac rupture, which generally occurred at 3 to 5 days after MI. Since matrix metalloproteinases (MMPs) play an important role in infarct healing, tissue repair and extracellular matrix (ECM) remodeling post-MI, we studied the temporal relationship of MMP expression and inflammatory response to cardiac rupture after acute MI. Male C57BL/6J mice were subjected to MI (induced by ligating the left anterior descending coronary artery) and killed 1, 2, 4, 7 or 14 days after MI. MMP-2 and MMP-9 activity in the heart were measured by zymography. Collagen content was measured by hydroxyproline assay. We found that after MI, MMP-9 activity increased as early as 1 day and reached a maximum by 2-4 days, associated with a similar increase in neutrophil and macrophage infiltration in the infarct area. MMP-2 started to increase rapidly within 4 days, reaching a maximum by 7 days and remaining high even at 14 days. Intense macrophage infiltration appeared by 4 days after MI and then gradually decreased within 7 to 14 days. Collagen content was unchanged until 4 days after MI, at which point it increased and remained high thereafter. Our data suggest that in mice, overexpression of MMP-2 and MMP-9 (possibly expressed mainly by neutrophils and macrophages) may lead to excessive ECM degradation in the early phase of MI, impairing infarct healing and aggravating early remodeling which in turn causes cardiac rupture.

Acute coronary syndrome as a cause of sudden death in patients with old myocardial infarction: a pathological analysis

Old myocardial infarction (OMI) is one of the most important pathological manifestations in sudden cardiac death. Fatal arrhythmia arising from a fibrotic scar has been determined as the cause of death in most cases with old myocardial infarction. However, the significance of acute plaque disruption/thrombosis of the coronary arteries in those patients has not been investigated. We examined a series of 33 hearts from individuals with OMI who died suddenly during the period from 1998 to 2001. Detailed coronary pathological findings on these hearts indicated fresh or recent rupture of the coronary plaque with thrombosis in 18 cases (55%). As a result of comprehensive analysis, the sudden deaths were explained by acute coronary syndrome in 18 cases (55%), fatal arrhythmia in eight (24%), cardiac pump failure in five (14%), and other causes in two (6%) cases. Our findings revealed that a new coronary plaque rupture independent of the old infarct was a major cause of sudden cardiac death with OMI.

Ruptured left ventricular pseudoaneurysm penetrating into the left pleural cavity

We experienced a rare case of ruptured left ventricular pseudoaneurysm penetrating into the left pleural cavity. A 77-year-old woman was first diagnosed with unstable angina due to sudden chest pain onset and abnormal electrocardiographic findings. In 2 days, massive left pleural effusion was recognized by chest X-ray, though subsequent computed tomographic scans did not show any aortic pathology. We observed her with left thoracentesis alone. Two days later, cardiac arrest suddenly occurred and emergency surgery was undertaken after resuscitation by percutaneous cardiopulmonary support. In surgery, a moderate amount of intrapericardial hematoma caused by rupture of a left ventricular pseudoaneurysm penetrating into the left pleural cavity was found and successfully repaired. This rare rupture of a left ventricular pseudoaneurysm penetrating into the left pleural cavity generated massive hemo-hydrothorax.

Early aortic valve cusp rupture in relapsing polychondritis

Aortic regurgitation associated with relapsing polychondritis usually occurs late in the disease as a result of aortic root dilatation. A case where aortic regurgitation occurred early and was due to cusp rupture with a normal aortic root is reported. The patient required urgent aortic valve replacement within six weeks of developing a murmur despite apparent control of inflammation with immunosuppressive treatment. The possibility of cusp rupture with sudden haemodynamic deterioration should be considered in patients with relapsing polychondritis who develop aortic regurgitation.

Usefulness of color Doppler flow imaging to distinguish ventricular septal defect from acute mitral regurgitation complicating acute myocardial infarction

Several studies have found 2-dimensional echocardiography and conventional spectral Doppler ultrasound useful in the assessment of ventricular septal defect (VSD), but few data exist regarding the usefulness of color Doppler flow imaging in evaluating this problem. Thus, the results of color flow imaging performed in 14 patients who presented with a recent acute myocardial infarction (AMI), hemodynamic instability and a new systolic murmur were evaluated. All patients underwent cardiac catheterization for definitive diagnosis, which proved to be VSD in 7 and acute mitral regurgitation in 7. VSD, identified by turbulent flow traversing the ventricular septum during ventricular systole, was correctly identified in all 7 patients with septal rupture. In the remaining 7 patients with a new murmur after AMI, mitral regurgitation was demonstrated as turbulent systolic flow in the left atrium by both color flow imaging and cine ventriculography. In all 14 patients with new murmurs, color flow imaging was 100% accurate for the presence or absence of VSD. Color flow imaging localized the septal defect to the apical septum (3), inferior septum (3) or both inferior and apical septal regions (1), and was 100% concordant for location compared with cineangiography, surgery and conventional Doppler echocardiographic techniques. Color flow imaging was accurate in identifying the presence and location of VSD complicating AMI, and accurately differentiated VSD from mitral regurgitation. Color flow imaging provides safe, rapid diagnosis of VSD complicating AMI, and may alleviate the need for diagnostic right-sided heart catheterization and preoperative cine ventriculography in these seriously ill patients.

Patterns of coronary artery disease in post-infarction ventricular septal rupture

Cardiac angiography was reviewed in 91 patients with post-infarction ventricular septal rupture. The results were compared with those of 123 stable survivors who had a positive submaximal exercise test early after infarction. Anterior infarction and occlusion of the infarct vessel were more common in those with ventricular septal rupture than in the comparison group. In the group with ventricular septal rupture there was more left ventricular damage, with aneurysm formation in two thirds, and coronary angiography showed more single than triple vessel disease. In the comparison group there was more triple vessel disease than single vessel disease. Angiographically demonstrable collaterals to the infarct territory were not seen or only very faintly seen in 82% of those with septal rupture. Well developed collaterals were seen in two thirds of the comparison group. These patterns of coronary disease suggest that ventricular septal rupture is more likely in patients with coronary occlusion and little or no collateral support to the infarct territory.

[A study of left ventricular rupture associated with acute myocardial infarction]

A report is presented on 9 cases of left ventricular rupture associated with acute myocardial infarction experienced at Tsuchiya Hospital from January 1983 to August 1987. These cases accounted for 2.6% of the 384 cases of acute myocardial infarction admitted during the same period. Cases of cardiac rupture were classified according to clinical symptoms and hemodynamic findings obtained into three types, blow out type, subacute type, and our newly added intermediate type. In the intermediate type, there is depression of blood pressure to the level of losing consciousness but improvement of blood pressure and consciousness through medical treatment and time is available to permit surgical treatment in comparison with the blow out type. The therapeutic results were studied by the types. Among the four cases of blow out type, closure of the ventricular rupture was made under the extracorporeal circulation in one case, release of tamponade only under thoracotomy in the CCU in one case, and medical treatment only in two case, but none of the cases survived. Surgical closure of the ventricular rupture was made in all the three cases of the subacute type and all the cases are surviving. Of the two cases of the intermediate type who underwent surgical closure of the ventricular rupture, only one case could be salvaged. In examining the risk factors of cardiac rupture, a high rate of cardiac rupture was observed in initial cases of myocardial infarction without a past history of angina attack and in cases of coronary occlusion without evidence of peripheral collateral flow by emergency coronary angiography.

Papillary muscle rupture complicating acute myocardial infarction. Treatment with mitral valve replacement and coronary bypass surgery

Six cases of complete or partial rupture of the papillary muscle after acute myocardial infarction are presented. All cases were treated by mitral valve replacement and concomitant coronary bypass surgery. An average delay of 3 days between rupture and operation occurred in the four patients with rupture of the main muscle trunk. The operative mortality rate was 50 percent. Such patients present with acute, florid left ventricular failure secondary to the severe mechanical burden imposed on the newly infarcted heart. The resulting valvular incompetence must be corrected by urgent mitral valve replacement if survival is to be lengthened. Patients with partial or apical head ruptures have a lesser degree of regurgitation and symptoms are largely dependent on intrinsic ventricular function. Both of our patients with partial muscle rupture presented with severe heart failure 2 to 4 months later, and both did well postoperatively. We believe that prompt operation without prolonged attempts at medical stabilization is the key to decreasing operative mortality, especially in instances of complete muscle rupture. Since ischemic heart disease remains the leading cause of death in such patients, coronary artery bypass surgery should be performed in conjunction with valve replacement.

Postinfarction ventricular septal defect: delayed closure with prolonged mechanical circulatory support

Three patients who had ventricular septal rupture and cardiogenic shock complicating an acute myocardial infarction were treated by prolonged circulatory assistance using intraaortic balloon pumping. Hemodynamic stabilization was obtained, and surgical repair was delayed for 19 to 27 days after initiation of circulatory support. All three patients survived the operation and were discharged from the hospital 13 to 19 days after operation. Prolonged intraaortic balloon pumping in such patients is safe and often induces hemodynamic stabilization. The patients may then be operated on under more favorable conditions, without risk of multisystem failure, and after fibrosis has developed around the septal rupture.

[Dysfunction of valvular prostheses. Results of surgical treatment]

Twenty six of malfunctioning valve prosthesis (one patient with two prosthesis) operated between may 1977 and may 1980 at the National Institute of Cardiology of Mexico are revised. Seventeen prosthesis were implanted in the mitral position and 10 in the aortic position. A comparative study is male between the different types of prosthesis, especially between the duramater and the Björk prosthesis. Clinical diagnosis of malfunctioning prosthesis was made in all the patients; cardiac catherization was done in 20 patients. Phono and Echocardiography were useful tools in most cases. The most frequent causes of prothesis malfunction were: thrombosis, valve rupture and para-valvular leaks. The Bjork prosthesis are the most thrombogenic of all. Valve rupture was prevalent with the duramater prosthesis. Five patients died (19%); acute dysfunction accounted most deaths. The duramater prosthesis have a similar percentage of dysfunction as the most accepted prosthesis; a suggestion is made to modify the supportive ring to make it more beneficial.

Two-dimensional echocardiographic identification of surgically correctable complications of acute myocardial infarction

The appearance of a new, loud systolic murmur in a patient with congestive heart failure after an acute myocardial infarction suggests a surgically correctable cause of the heart failure. Using two-dimensional echocardiography, we studied 14 patients who presented in this manner. Four patients had rupture of a papillary muscle with a flail mitral valve. All four had surgery; three survived. Five patients had fibrosis of the posteromedial papillary muscle. All five had surgery; three survived. Five patients had a ventricular septal defect. Three of the five had surgery; one survived. Two-dimensional echocardiography is useful in studying patients with a new systolic murmur and congestive heart failure after acute myocardial infarction to detect surgically correctable structural defects.