Ventriculography to Identify Ventricular Free-Wall Rupture in Acute Coronary Syndrome

Abstract: A 76-year-old previously well female with late-presentation acute coronary syndrome underwent left ventriculography, which demonstrated contrast leak into the pericardium consistent with left ventricular free-wall rupture. Confirmatory imaging, including echocardiography, was performed. Our case highlights the persistent utility of ventriculography as an imaging modality to identify free-wall rupture in acute coronary syndromes.

J INVASIVE CARDIOL 2015;27(11):E256-E257

Key words: cardiac imaging, congestive heart failure, ventriculography

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Case Presentation

A 76-year-old previously healthy female presented late in the evening with an acute coronary syndrome. Initial investigation demonstrated elevated cardiac biomarkers and electrocardiography demonstrated inferior and anterior ST elevation. Chest x-ray demonstrated mild congestive heart failure. Coronary angiography was pursued.  

Due to the late presentation, hypotension, and somnolence, initial imaging was performed with left ventriculography. Anterior akinesis, apical dyskinesis, and evidence of ventricular free-wall rupture (Figure 1, Video 1) were observed, along with an end-diastolic pressure of 22 mm Hg. Coronary imaging demonstrated a right dominant system with severe disease in the circumflex, and an occlusion of the distal left anterior descending with no apical filling (Figure 1). Bedside echocardiography confirmed significant blood in the pericardium with clot overlying the anterior wall and right ventricle (Figure 1, Video 2). 

Discussion

Left ventricular free-wall rupture is a recognized complication of myocardial infarction. It is observed in <2% of cases, but is often fatal, accounting for 14%-27% of in-hospital mortalities.^1,2 Recent studies show a gradual decrease in mortality associated with left ventricular rupture attributed to the increasing use of reperfusion strategies as first-line therapy in acute myocardial infarction.³ 

The diagnosis of left ventricular free-wall rupture is not always clinically evident, and there is some disagreement regarding the best imaging modality to diagnose and visualize ruptures.⁴ Modalities such as echocardiography, ventriculography, pericardiocentesis, and hemodynamic monitoring are suggested to diagnose rupture.^4,5 The goal of imaging is rapid early identification to facilitate intervention, as many patients often succumb to this complication. 

Ventriculography, as performed in this patient, may be a valuable tool in the early diagnosis of ventricular rupture.  Many centers are shifting away from ventriculography as part of the angiographic work-up; however, our case demonstrates its persistent role in the rapid diagnosis and subsequent initiation of a therapeutic plan.  

Our case highlights the potential utility of ventriculography in the diagnosis of left ventricular free-wall rupture in an acute myocardial infarction case. 

References

1.    Stevenson WG, Linssen GC, Havenith MG, Brugada P, Wellens HJ. The spectrum of death after myocardial infarction: a necropsy study. Am Heart J. 1989;118:1182-1188.

2.    Pohjola-Sintonen S, Muller JE, Stone PH, et al. Ventricular septal and free-wall rupture complicating acute myocardial infarction: experience in the Multicenter Investigation of Limitation of Infarct Size. Am Heart J. 1989;117:809-818.

3.    Figueras J, Alcalde O, Barrabés JA, et al. Changes in hospital mortality rates in 425 patients with acute ST-elevation myocardial infarction and cardiac rupture over a 30-year period. Circulation. 2008;118:2783-2789.

4.    Krakau I, Lapp H, Wolfertz J, Gülker H. Direct visualization of left ventricular free-wall rupture by levocardiography. Catheter Cardiovasc Interv. 2002;56:238-242.

5.    Davis N, Sistino JJ. Review of ventricular rupture: key concepts and diagnostic tools for success. Perfusion. 2002;17:63-67.

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From the University of Manitoba, Department of Cardiology, Manitoba, Canada.

Disclosure: The authors have completed and returned the ICMJE Form for Disclosure of Potential Conflicts of Interest. They report no conflicts of interest regarding the content herein.

Manuscript submitted March 30, 2015, provisional acceptance given April 6, 2015, final version accepted April 22, 2015.

Address for correspondence: Malek Kass, MD, FRCPC, Assistant Professor of Medicine, Director, Structural Intervention, University of Manitoba, Section of Cardiology, Y3517-409 Tache Avenue, Winnipeg, Manitoba, Canada R2H 2A6. Email: mkass@sbgh.mb.ca