Bedside Diagnosis of Cardiac Rupture by Contrast Echocardiography
A 67-year-old woman was admitted to our medical center complaining of prolonged chest pain lasting 2 hours. Electrocardiography showed ST-segment elevation in leads I, aVL, and V2 to V5 without reciprocal ST depression. Echocardiography revealed apical ballooning, basal hyperkinesis, and a left ventricular outflow pressure gradient of 110 mm Hg associated with systolic anterior movement of the anterior mitral leaflet. Laboratory analysis revealed a white cell count of 8560/mm3, and the creatine kinase level was 304 IU/dL. Emergency coronary arteriography showed no fixed coronary arterial stenosis. Left ventriculography revealed extensive akinesis from the apex to the mid portion of the left ventricle, with hypercontraction of the basal segment compatible with Takotsubo cardiomyopathy (Figure 1). Oral administration of 20 mg metoprolol 3 times daily was initiated. The maximum serum level of creatine kinase was 348 IU/dL. On hospital day 7, the patient noted dyspnea and displayed a distended jugular vein even in a sitting position. Bedside echocardiography was performed immediately, demonstrating moderate pericardial effusion with slight dilatation of the inferior vena cava, a compressed right atrium, apical ballooning, basal hyperkinesis, and a left ventricular outflow pressure gradient of 110 mm Hg. Contrast echocardiography (Toshiba Aplio) after an intravenous bolus injection of Levovist (Schering AG) (200 mg/mL, 2 mL) revealed bubble signals in the pericardial cavity, demonstrating oozing cardiac rupture of Takotsubo cardiomyopathy on intermittent imaging with 1.5 harmonic pulse rate subtraction (Figure 2A through 2C and the echo cine). Subsequent cardiac CT indicated that the pericardial fluid CT value was equal to that for the aorta (Figure 3). Emergency surgery was performed to repair the rupture site. Cardiac rupture is a life-threatening complication of acute myocardial infarction and Takotsubo cardiomyopathy. Definitive bedside diagnosis of cardiac rupture is crucial to clinical decision making. Recent advances in contrast echocardiography allow evaluation of myocardial microcirculation and delineation of the endocardial border at the bedside. Intermittent 1.5 harmonic pulse rate subtraction imaging offers microbubble-sensitive and -specific imaging. Demonstration of microbubbles in the pericardial space offers direct proof of cardiac rupture. Contrast echocardiography may represent a clinically useful modality for providing quick and definitive diagnosis of oozing rupture in real time at the bedside.
The online-only Data Supplement, which contains a movie, can be found at http://circ.ahajournals.org/cgi/content/full/112/24/e354/DC1.