Cardiac Rupture Following Myocardial Infarction With Non-Obstructive Coronary Artery Disease

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J INVASIVE CARDIOL 2024. doi:10.25270/jic/24.00323. Epub November 18, 2024.

A 71-year-old man with a history of smoking presented to the emergency room of our hospital complaining of long-lasting angina symptoms. Upon physical examination, he was hypotensive.

An electrocardiogram showed an ST-segment depression in leads V2 to V4 (Figure 1), and the high-sensitivity troponin test showed 9411 ng/l. A transthoracic echocardiogram revealed left ventricle anterolateral wall hypokinesia and pericardial effusion (Video 1); the ascending aorta was found to be normal. Coronary angiography showed only a systolic compression of the middle tract of the left anterior descending artery, as in the case of a myocardial bridge (Video 2).

Due to a sudden deterioration of the patient’s hemodynamic parameters, an under xiphoid pericardiocentesis was attempted with blood removal; however, the patient died immediately upon the attempt. The autopsy clearly demonstrated that an anterior left ventricle free-wall rupture was the cause of death (Figure 2). Long-axis cut of the heart revealed a cardiac laceration in the context of a necrotic-hemorrhagic infarction, as per transmural necrosis (Figures 3, 4). Coronary inspection confirmed the vessels’ patency. Hematoxylin and eosin staining showed a massive transmural interstitial neutrophilic infiltrate (Figure 5); the neutrophils displaced the disarranged cardiomyocytes exhibiting loss of the nucleus and hypereosinophilic cytoplasm with lack of striations (Figure 6).

To our knowledge, only 3 cases of free-wall rupture after myocardial infarction with non-obstructive coronary artery disease (MINOCA) have been reported. The latter cases^1-4 involved women presenting with ST-elevation. Our case is the first in which a mechanical complication was described in a man with non-ST-elevation myocardial infarction at hospital investigation. We assume that our case was caused by a prolonged coronary artery spasm/thromboembolism that was initially misdiagnosed as transmural necrosis, leading to late spontaneous resolution/lysis and the resulting MINOCA.

Affiliations and Disclosures

Alessio Arrivi, MD, PhD, FESC¹; Martina Sordi, MD¹; Francesca Coppa, MD²; Tiziana Macciò, MD²; Serenella Conti, MD³

From the ¹Divison of Cardiology, Santa Maria Hospital, Terni, Italy; ²Divison of Pathology, Santa Maria Hospital, Terni, Italy; ³Division of Cardiology, S. Matteo degli Infermi Hospital, Spoleto, Italy.

Disclosures: The authors report no financial relationships or conflicts of interest regarding the content herein.

Consent statement: Informed consent for the publication is not available as the patient is deceased; nevertheless, all sensitive data has been anonymized.

Address for correspondence: Alessio Arrivi, MD, PhD, FESC, Santa Maria University Hospital, Via Tristano di Joannuccio 1, 05100, Terni, Italy. Email: alessio.arrivi@libero.it

References

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2. Giavarini A, Ippolito S, Tagliasacchi MI, Gelpi G. A rescued left ventricle free wall rupture in MINOCA. Eur Heart J. 2021;42(14):1446. doi:10.1093/eurheartj/ehaa1048

3. Aimo A, Di Paolo M, Castiglione V, et al. Scared to death: emotional stress causing fatal myocardial infarction with nonobstructed coronary arteries in women. JACC Case Rep. 2020;2(15):2400-2403. doi:10.1016/j.jaccas.2020.08.010

4. Roth CP, Qarmali M, Litovsky SH, Brott BC. Myocardial rupture after small acute myocardial infarction in the absence of coronary artery disease. Cardiovasc Pathol. 2018;37:26-29. doi:10.1016/j.carpath.2018.08.004