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(Circulation. 2007;115:e457-e459.)
© 2007 American Heart Association, Inc.

Images in Cardiovascular Medicine

Intramural Dissecting Hemorrhage of the Myocardium

Cosima Jahnke, MD; Roland Hetzer, MD; Takeshi Komoda, MD; Eckart Fleck, MD; Ingo Paetsch, MD

From the Department of Internal Medicine/Cardiology (C.J., E.F., I.P.) and Department of Cardiothoracic Surgery (R.H., T.K.), German Heart Institute, Berlin, Germany.

Correspondence to Ingo Paetsch, MD, Internal Medicine/Cardiology, German Heart Institute Berlin, Augustenburger Platz 1, 13353 Berlin, Germany. E-mail paetsch{at}dhzb.de

After suffering anterior myocardial infarction 3 months previously, a 59-year-old male patient with persistent dyspnea (New York Heart Association classification II) underwent a follow-up examination.

A 12-lead ECG showed chronic ST elevation (V1 through V4) indicating left ventricular anterior aneurysm; no significant pulmonary congestion was present (Figure 1A and 1B). On echocardiography, left ventricular ejection fraction was severely depressed, and a myocardial flap was seen in the left ventricular apex; in addition, a mostly echo-free apical space, together with thrombus formation, suggested contained myocardial rupture or pseudoaneurysm formation. However, nearby field artifacts prohibited clear distinction of the myocardial and pericardial layers (Figure 1C and Movie I).

View larger version (114K): [in this window] [in a new window]   Figure 1. A, Twelve-lead ECG. B, Chest x-ray (posteroanterior and lateral view). C, Transthoracic echocardiography in 4-chamber orientation. The white arrow indicates the apical myocardial flap.

On cine magnetic resonance imaging, apical dyskinesia and a thrombotic mass in the left ventricle were diagnosed. In addition, localized myocardial tearing and a flap showing pulsing synchronous movement were visible; no communication with the normally sized right ventricle existed (Figure 2A and 2C, Movie II).

View larger version (94K): [in this window] [in a new window]   Figure 2. A through D, Cardiac magnetic resonance imaging in 4-chamber (A and B) and short-axis orientation (C and D), using cine (left) and delayed-enhancement sequences (right). The white arrow in A indicates the site of myocardial dissection; black arrows in C indicate the myocardial flap forming the inner layer of a partially thrombosed neocavitation. Its outer layer is represented by scarred myocardium (brightly enhanced layer in B and D). E and F, Intraoperative views of the left ventricular apex. An intact epicardium and myocardial scar (white arrows in E) were noted. After incision of the apex, thrombotic material poured out (white arrows in F).

Delayed-enhancement magnetic resonance imaging (intravenous dosage of 0.2 mmol/kg of Gad-DTPA; inversion recovery delay 220 ms; delayed time 12 minutes) revealed an intramyocardial hematoma, which was clearly delineated by an endomyocardial layer toward the left ventricular cavity, and a scarred myocardium toward the epicardial border, corroborating the diagnosis of an intramural dissecting hemorrhage (Figure 2B and 2D).

This entity accounts for fewer than 10% of cardiac ruptures and may occur after myocardial infarction, chest trauma, or surgery, or even spontaneously.^1,2 Preoperative diagnosis is difficult, with differential diagnosis including pseudoaneurysm and intracavitary thrombus. Considering the poor prognosis of patients treated medically (less than 10% survival), corrective surgery is usually the treatment of choice. Our patient recovered uneventfully thereafter.³

	Disclosures

Top Disclosures References

 
None.

	Footnotes

 
The online-only Data Supplement, consisting of Movies I and II, is available with this article at http://circ.ahajournals.org/cgi/content/full/115/19/e457/DC1.

	References

Top Disclosures References

 
1. Harpaz D, Kriwisky M, Cohen AJ, Medalion B, Rozenman Y. Unusual form of cardiac rupture: sealed subacute left ventricular free wall rupture, evolving to intramyocardial dissecting hematoma and to pseudoaneurysm formation—a case report and review of the literature. J Am Soc Echocardiogr. 2001; 14: 219–227.[CrossRef][Medline] [Order article via Infotrieve]

2. Hosaka Y, Kodama M, Chinushi M, Washizuka T, Sugiura H, Satou K, Aizawa Y. Intramyocardial hemorrhage caused by myocardial contusion. Circulation. 2004; 109: 277.[Free Full Text]

3. Pliam MB, Sternlieb JJ. Intramyocardial dissecting hematoma: an unusual form of subacute cardiac rupture. J Card Surg. 1993; 8: 628–637.[Medline] [Order article via Infotrieve]

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Circulation 2007 115: 2459. [Extract] [Full Text]

This Article Extract Full Text (PDF) Data Supplement Alert me when this article is cited Alert me if a correction is posted Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Download to citation manager Request Permissions Citing Articles Citing Articles via Google Scholar Google Scholar Articles by Jahnke, C. Articles by Paetsch, I. Search for Related Content PubMed PubMed Citation Articles by Jahnke, C. Articles by Paetsch, I. Related Collections CT and MRI Related Article