Diagnosis of Free-Wall Rupture by Left Ventricular Angiogram After Inferior ST-Segment–Elevation Myocardial Infarction
A 67-year-old man with type 2 diabetes mellitus presented after an out-of-hospital cardiac arrest with pulseless electric activity (PEA) preceded by significant chest discomfort and syncope. Cardiopulmonary resuscitation was started for PEA arrest with return of spontaneous circulation after 20 minutes. His initial ECG showed an acute inferior ST-segment–elevation myocardial infarction (STEMI; Figure 1). In the emergency department, he experienced another PEA arrest and an ECG showed evidence of a moderate pericardial effusion. Attempts on pericardiocentesis were unsuccessful, and he was brought to the catheterization laboratory in cardiogenic shock on vasopressors.
Emergent coronary angiogram demonstrated a completely occluded proximal right coronary artery with an intracoronary thrombus with moderate disease in the left anterior descending artery and left circumflex arteries (Figure 2A and 2B). Transthoracic echocardiogram could not clearly identify a free-wall rupture, so a left ventricular angiogram was performed and showed evidence of a posterobasal inferior wall rupture with double density in the right and trabeculated appearance in the left anterior oblique views attributed to extravasated and clotted blood in the pericardium (Figure 2C and 2D and Movies I and II in the online-only Data Supplement). Intraoperative transesophageal echocardiogram demonstrated coagulated blood in the pericardium and site of cardiac rupture (Figure 3A and 3B and Movie III in the online-only Data Supplement).
The patient required ≈60 minutes of external chest compression support to maintain peripheral perfusion. The patient was rapidly transported to the operating room for emergent cardiac surgery. The pericardium was opened, and hemodynamics rapidly improved. The patient was quickly supported on cardiopulmonary bypass. On direct inspection, an extensive right ventricular infarct was identified, extending along the basal inferior wall of the left ventricle adjacent to the septum. The myocardium was extremely fragile, and free-wall rupture was identified. Patch repair of the rupture was expeditiously performed without complication. Because of the extensive right ventricular infarct and duration of external cardiac compressions, extracorporeal membrane oxygenation support was required. Prolonged CPR had also caused extensive rib fracturing, leading to diffuse bleeding, which was managed with direct ligation/cautery of bleeding sites and multiple rounds of intravascular blood product therapy. The patient never demonstrated signs of neurologic recovery after prolonged CPR and was found to have a large intracranial bleed with uncal herniation. Support was withdrawn 8 days after presentation.
Free-wall cardiac rupture is more common in the anterior and lateral walls of the left ventricle and is associated with old age, lack of collateral circulation, or ischemic preconditioning and presentation with first myocardial infarction, as in our patient. The overall incidence of cardiac rupture after STEMI ranges from 0.8% to 6.2%.1 The most common presentation is with PEA and pericardial effusion; however, nearly half of the deaths from cardiac rupture occur as out-of-hospital sudden deaths and never present to the hospital.2 Cardiac rupture typically occurs within 1 to 4 days after the infarct; however, widespread use of fibrinolytic therapy and percutaneous coronary intervention has led to a decline in incidence and a trend toward earlier rupture. A recent series demonstrated a reduction in the overall incidence of free-wall rupture in the modern era, at 1.3%; however, 47.1% of these patients experienced free-wall rupture within the first 24 hours, with an extremely high mortality rate of 88.2%.3 Even in the older era of medical therapy, ≥13% to 28% of ruptures occurred within 24 hours of onset of infarction, when inflammation and necrosis are not expected to be as prominent.4
Cardiac rupture needs to be ruled out in patients presenting with a PEA and pericardial effusion in the setting of a STEMI. In equivocal cases where the diagnosis is not clear by echo, a left ventriculogram can be rapidly diagnostic. Even with early diagnosis, surgical mortality remains extremely high.
The online-only Data Supplement is available with this article at http://circ.ahajournals.org/lookup/suppl/doi:10.1161/CIRCULATIONAHA.115.015951/-/DC1.
- © 2015 American Heart Association, Inc.
- Figueras J,
- Alcalde O,
- Barrabés JA,
- Serra V,
- Alguersuari J,
- Cortadellas J,
- Lidón RM