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Left Ventricular Free-Wall Rupture After Late-Admission STEMI
J INVASIVE CARDIOL 2022;34(5):E416-E417.
Key words: left ventricle, STEMI
A 93-year-old female patient with previous history of hypertension, atrial fibrillation, and ischemic stroke presented at the emergency department due to epigastric pain, malaise, sweating, and somnolence with 24 hours of evolution. Clinical examination revealed irregular cardiac rhythm and impaired peripheral perfusion. Blood pressure was 130/87 mm Hg and heart rate was 114 bpm. Inferior-lateral and right ventricular ST-segment elevation were present in the electrocardiogram. Bedside echocardiogram showed a severe ventricular dysfunction and pericardial effusion with an adherent clot, without identifying the perforation site.
Fluid replacement and vasopressor were initiated as blood pressure began to drop. Orotracheal intubation was performed due to respiratory failure. The patient was transferred to the catheterization laboratory for emergency cardiac catheterization. Coronary angiography showed a thrombotic occlusion of the distal left circumflex artery (LCX) and proximal marginal branch. The proximal left anterior descending artery (LAD) and right coronary artery (RCA) had severe lesions (Figure 1). Due to hemodynamic deterioration, pericardiocentesis was performed with a pigtail catheter (Figure 2) with transient improvement, but failed to empty the pericardium due to continuous blood filling. Hemodynamics continued to deteriorate and several cardiac arrests developed, with transient returns of spontaneous circulation. After considering the condition irreversible, we injected contrast in the pericardium to confirm diagnosis, showing 2 perforations in the left ventricular free wall (Video 1). The patients died minutes later.
This case illustrates a rare but catastrophic complication of acute myocardial infarction, ie, acute rupture of the left ventricular free wall. The mortality of this condition reaches almost 100% .1 The presentation is usually sudden death, mainly out-of-hospital. The incidence and mortality increase with delayed revascularization.2
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.3 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.
Affiliations and Disclosures
From the 1Imperial Hospital de Caridade, Florianopolis, Brazil; and 2Hospital de Clinicas de Porto Alegre, Porto Alegre, Brazil.
Disclosure: The authors have completed and returned the ICMJE Form for Disclosure of Potential Conflicts of Interest. The authors report no conflicts of interest regarding the content herein.
The authors report that patient consent was provided for publication of the images used herein.
Manuscript accepted January 10, 2022.
Address for correspondence: Gustavo Neves de Araujo, Rua Ramiro Barcelos 2350, Porto Alegre, RS, Brazil. Email: gustavon.araujo@gmail.com
References
1. Moreno R, López-Sendón J, García E, Pérez de Isla L, et al. Primary angioplasty reduces the risk of left ventricular free wall rupture compared with thrombolysis in patients with acute myocardial infarction. J Am Coll Cardiol. 2002;39(4):598-603. doi:10.1016/s0735-1097(01)01796-x
2. Becker RC, Gore JM, Lambrew C, et al. A composite view of cardiac rupture in the United States National Registry of Myocardial Infarction. J Am Coll Cardiol. 1996;27(6):1321‐1326. doi:10.1016/0735-1097(96)00008-3
3. Reardon MJ, Carr CL, Diamond A, Letsou GV, Safi HJ, Espada R. Ischemic left ventricular free wall rupture: prediction, diagnosis and treatment. Ann Thorac Surg. 1997;64(5):1509-1513. doi:10.1016/S0003-4975(97)00776-5
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