Intramural Dissecting Hemorrhage of the Myocardium
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).
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).
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
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.
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.
Hosaka Y, Kodama M, Chinushi M, Washizuka T, Sugiura H, Satou K, Aizawa Y. Intramyocardial hemorrhage caused by myocardial contusion. Circulation. 2004; 109: 277.