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Timely Diagnosis of Left Ventricular Posterior Wall Rupture by Echocardiography: A Case Report
Maryam Esmaeilzadeh,Ahmad Mirdamadi,Majid Kiavar,Gholamreza Omrani
Journal of Tehran University Heart Center , 2010,
Abstract: Left ventricular free wall rupture is responsible for up to 10% of in-hospital deaths following myocardial infarction. It is mainly associated with posterolateral myocardial infarction, and its antemortem diagnosis is rarely made.One of the medical complications of myocardial infarction is the rupture of the free wall, which occurs more frequently in the anterolateral wall in hypertensives, women, and those with relatively large transmural myocardial infarction usually 1-4 days after myocardial infarction.We herein present the case of a 66-year-old man suffering inferior wall myocardial infarction with abrupt hemodynamicdecompensation 9 days after myocardial infarction. Emergent transthoracic echocardiography revealed massive pericardialeffusion with tamponade, containing a large elongated mass measuring 1 × 8cm suggestive of hematoma secondary to cardiac rupture. In urgent cardiac surgery, the posterior wall between the left coronary artery branches was ruptured.
Left ventricular free wall impeding rupture in post-myocardial infarction period diagnosed by myocardial contrast echocardiography: Case report
Maria da Trindade, Jeane Tsutsui, Ana Rodrigues, Márcia Caldas, José Ramires, Wilson Mathias
Cardiovascular Ultrasound , 2006, DOI: 10.1186/1476-7120-4-7
Abstract: A 50-year-old man with acute myocardial infarction in the lateral wall underwent myocardial contrast echocardiography for the evaluation of myocardial perfusion in the third day post-infarction. A perfusion defect was detected in lateral and inferior walls as well as the presence of contrast extrusion from the left ventricular cavity into the myocardium, forming a serpiginous duct extending from the endocardium to the epicardial region of the lateral wall, without communication with the pericardial space. Magnetic resonance imaging confirmed the diagnosis of impending rupture of the left ventricular free wall. While waiting for cardiac surgery, patient presented with cardiogenic shock and died. Anatomopathological findings were consistent with acute myocardial infarction in the lateral wall and a left ventricular free wall rupture at the infarct site.This case illustrates the early diagnosis of left ventricular free wall rupture by contrast echocardiography. Due to its ability to be performed at bedside this modality of imaging has the potential to identify this catastrophic condition in patients with acute myocardial infarction and help to treat these patients with emergent surgery.Left ventricular free wall rupture occurs in up to 10% of the in-hospital deaths following acute myocardial infarction (AMI), usually between 3 to 6 days after the infarction. It typically involves the anterior or lateral wall, in the terminal region of the left anterior descending coronary artery distribution. It is associated with transmural infarctions involving at least 20% of the left ventricle, and it rarely occurs in areas with good collateral blood supply [1,2]. The local factors that lead to myocardial rupture are thinness of the apical wall at terminal end of blood supply, poor collateral flow and shearing effect of muscular contraction against an inert and stiffened necrotic area. Rupture of the left ventricular free wall usually leads to hemopericardium and death from cardiac
Contained Left Ventricular Free Wall Rupture following Myocardial Infarction  [PDF]
Arthur Shiyovich,Lior Nesher
Case Reports in Critical Care , 2012, DOI: 10.1155/2012/467810
Abstract: Rupture of the free wall of the left ventricle occurs in approximately 4% of patients with infarcts and accounts for approximately 20% of the total mortality of patients with myocardial infractions. Relatively few cases are diagnosed before death. Several distinct clinical forms of ventricular free wall rupture have been identified. Sudden rupture with massive hemorrhage into the pericardium is the most common form; in a third of the cases, the course is subacute with slow and sometimes repetitive hemorrhage into the pericardial cavity. Left ventricular pseudoaneurysms generally occur as a consequence of left ventricular free wall rupture covered by a portion of pericardium, in contrast to a true aneurysm, which is formed of myocardial tissue. Here, we report a case of contained left ventricular free wall rupture following myocardial infarction. 1. Introduction Rupture of the free wall of the left ventricle occurs in approximately 4% of patients with myocardial infarction (MI) and accounts for approximately 20% of mortality of these patients [1, 2]. Premortem diagnosis of rupture is made in approximately 15% of in-hospital deaths from acute MI in a coronary care unit [3]. However, one series of autopsies claims that up to 31% of MI fatalities had cardiac rupture. Hence, relatively few cases of left ventricular free wall rupture (LVFWR) are diagnosed before death. Nevertheless, the increased availability of bedside echocardiography has contributed to a progressive rise in the number of cases of LVFWR being diagnosed and reported. Several distinct clinical forms of ventricular free wall rupture have been identified [4]. Sudden rupture with massive hemorrhage into the pericardium is the most common form; in a third of the cases, the course is subacute with slow and sometimes repetitive hemorrhage into the pericardial cavity [5]. Left ventricular pseudoaneurysm is a variant of left ventricular rupture that generally occurs as a consequence of LVFWR covered by a portion of pericardium. Here, we report a case of contained left ventricular free wall rupture following myocardial infarction. 2. Patient Description An 80-year-old retired female resident of a home for the aged was admitted with recent complaints of dyspnea, dizziness, and a falling episode with a possible loss of consciousness. Her personal history revealed mild dementia, Parkinson’s disease treated with carbidopa and levodopa, hypertension treated by nifedipine, and dyslipidemia treated by statins. Additional medications included acetylsalicylic acid (100?mg?qd), calcium supplements, and
Survival after Left Ventricular Free Wall Rupture in an Elderly Woman with Acute Myocardial Infarction Treated Only Medically
Víctor Hugo Roa-Castro,Ervin Molina-Bello,Hector Valenzuela-Suárez,Tobías Rotberg-Jagode,Nilda Espinola-Zavaleta
Case Reports in Vascular Medicine , 2012, DOI: 10.1155/2012/728602
Abstract: Pseudoaneurysm of the left ventricle is rare and may occur as a result of transmural myocardial infarction. The course of rupture after acute myocardial infarction varies from a catastrophic event, with an acute tear leading to immediate death (acute rupture), or slow and incomplete tear leading to a late rupture (subacute rupture). Incomplete rupture may occur when the thrombus and haematoma together with the pericardium seal the rupture of the left ventricle and may develop into a pseudoaneurysm. Early diagnosis and treatment is essential in this condition. Two-dimensional color Doppler echocardiography is the first-choice method for most patients with suspected left ventricular pseudoaneurysm (LVP) and suggests left ventricular rupture in 85% to 90% of patients. We report the case of an 87-year-old woman presenting with symptoms and findings of myocardial infarction and left ventricular free wall rupture with a pseudoaneurysm formation diagnosed by echocardiography and confirmed on CT, MRI, and NM. She received only intense medical treatment, because she refused surgery with a favorable outcome. After 24-month followup, she is in NYHA functional class II. The survival of this patient is due to the contained pseudoaneurysm by dense pericardial adhesions, related to her previous coronary bypass surgery.
Survival after Left Ventricular Free Wall Rupture in an Elderly Woman with Acute Myocardial Infarction Treated Only Medically  [PDF]
Víctor Hugo Roa-Castro,Ervin Molina-Bello,Hector Valenzuela-Suárez,Tobías Rotberg-Jagode,Nilda Espinola-Zavaleta
Case Reports in Vascular Medicine , 2012, DOI: 10.1155/2012/728602
Abstract: Pseudoaneurysm of the left ventricle is rare and may occur as a result of transmural myocardial infarction. The course of rupture after acute myocardial infarction varies from a catastrophic event, with an acute tear leading to immediate death (acute rupture), or slow and incomplete tear leading to a late rupture (subacute rupture). Incomplete rupture may occur when the thrombus and haematoma together with the pericardium seal the rupture of the left ventricle and may develop into a pseudoaneurysm. Early diagnosis and treatment is essential in this condition. Two-dimensional color Doppler echocardiography is the first-choice method for most patients with suspected left ventricular pseudoaneurysm (LVP) and suggests left ventricular rupture in 85% to 90% of patients. We report the case of an 87-year-old woman presenting with symptoms and findings of myocardial infarction and left ventricular free wall rupture with a pseudoaneurysm formation diagnosed by echocardiography and confirmed on CT, MRI, and NM. She received only intense medical treatment, because she refused surgery with a favorable outcome. After 24-month followup, she is in NYHA functional class II. The survival of this patient is due to the contained pseudoaneurysm by dense pericardial adhesions, related to her previous coronary bypass surgery. 1. Background Left ventricular free wall rupture (LVFWR) in myocardial infarction (MI) is often fatal, and only a few patients may undergo operation. The cardiac rupture may be clinically undetected and lead to pseudoaneurysm [1–3]. Left ventricular pseudoaneurysm (LVP) is formed when cardiac rupture is contained by adherent pericardium or scar tissue [4]. Two-dimensional echo is the first-choice method for patients with suspected LVP and suggests left ventricular rupture in 85% to 90% of patients [5]. The potential use of 3D echo in assessing the location and complex geometry of ventricular rupture site has been demonstrated [6]. The main aim of this case is to describe the long survival of a woman in the ninth decade of life with acute LVFWR and LVP formation after MI. 2. Case Report An 87-year-old woman with history of hypothyroidism, systemic arterial hypertension, anterior MI with an LV apical aneurysm, and coronary artery bypass graft to the left anterior descending in 1997 presented to the emergency room with an epigastric discomfort that had begun 24 hours earlier and a diagnosis of acute MI was made. At admission she was hemodynamically stable. Vital signs included a BP of 130/70?mmHg, HR 70?beats/min, RR of 16, temperature of 36.5°C, and
Rotura de pared libre de ventriculo izquierdo tras infarto agudo del miocardio. A propósito de un caso. Left ventricular free wall rupture after acute myocardial infarction. Report of a case.
álvaro Lahoz Tornos,Victor Glen Ray López,Ramón Arcas Meca,Luis Falcón Ara?a
Revista Cubana de Cardiología y Cirugía Cardiovascular , 2011,
Abstract: Rupture of the left ventricular free wall is a rare complication of acute myocardial infarctionusually occurs between 1st and 5th days after acute myocardial infarction. We reported a newcase of cardiac rupture successfully treated by surgery without cardiopulmonary bypass. Webelieve that the departments of general and thoracic surgery in hospitals without cardiacsurgery, could take this type of intervention to prevent the disastrous consequences of a longinter-center transfer.
Sutureless off-pump repair of post-infarction left ventricular free wall rupture
Hunaid A Vohra, Samena Chaudhry, Christopher MR Satur, Mary Heber, Rob Butler, Paul D Ridley
Journal of Cardiothoracic Surgery , 2006, DOI: 10.1186/1749-8090-1-11
Abstract: Left ventricular free wall rupture post myocardial infarction has a high mortality and therefore, rarely presents to the cardiac surgeon. Conventional approaches to this condition include ventricular repair with teflon buttressed sutures using cardiopulmonary bypass (CPB). Coronary artery bypass grafting may be performed concomitantly. Some authors have suggested sutureless techniques with or without cardiopulmonary bypass for this condition. We report a case of off-pump repair with bovine pericardial patches using Gelatine-Resorcin-Formalin (GRF) glue.A 47 year old man presented to the Emergency department with central chest pain. Lateral myocardial infarction (MI) was confirmed by typical changes in leads I, AVL and V6 and raised troponin T levels. The patient was not thombolysed. He was haemodynamically stable initially and a coronary angiogram was contemplated. However, before this could be performed, he developed further chest pain and became haemodynamically unstable with tachycardia, hypotension and collapse (at 48 hours). An urgent trans- thoracic echocardiogram (TTE) showed a pericardial effusion. Left ventricular (LV) free wall rupture was suspected. Contrast-enhanced computed tomography (CT) of the chest was performed which confirmed this, as well as a large pericardial effusion (figure 1). He was transferred from the referring hospital to the nearest cardiothoracic centre (one hour journey) for surgical repair. On arrival, it was felt that he would not have survived a trip to the catheter lab. A peri-operative trans-oesophageal echocardiogram (TOE) demonstrated pericardial tamponade and left ventricular free wall rupture in the region supplied by the circumflex artery. Surgery was performed via a median sternotomy. A large amount of blood and clot was removed from the pericardium with immediate haemodynamic improvement. A large recent infarction was identified involving the obtuse margin of the heart. This part of the myocardium was typically oedematous
Double rupture of interventricular septum and free wall of the left ventricle, as a mechanical complication of acute myocardial infarction: a case report
Elias I Rentoukas, George A Lazaros, Andreas P Kaoukis, Evangellos P Matsakas
Journal of Medical Case Reports , 2008, DOI: 10.1186/1752-1947-2-85
Abstract: In this report we present the unusual case of a 70-year-old woman with acute anteroseptal myocardial infarction, which was complicated by a combined rupture of the interventricular septum near the apex, and the free wall of the left ventricle with concomitant formation of a pseudoaneurysm. The double myocardial rupture was accidentally discovered 10 days later with echocardiography, when the patient, complaining only of mild exertional dyspnea, was hospitalized for a scheduled coronary angiography. The patient underwent successful surgical correction of the double myocardial rupture along with by-pass grafting.This report highlights the importance of comprehensive noninvasive predischarge diagnostic evaluation of all postinfarct patients, since serious and potentially life-threatening complications might have not been suspected on clinical grounds.Cardiac ruptures are serious and life-threatening mechanical complications of acute myocardial infarction (AMI). Types of rupture include left ventricle (LV) free-wall rupture (FWR), ventricular septal defect (VSD), and papillary muscle rupture (PMR). Double myocardial rupture (DMR) is defined as the coexistence of two of the above-mentioned forms of rupture. It complicates approximately 0.3% of AMI with the most frequent combination being FWR and VSD [1]. Small autopsy series report that DMR is seen in 13% of patients with FWR and in approximately 16% of patients with VSD [1]. The contribution of 2-D echocardiography and color Doppler in the early diagnosis of these lesions is well established [2]. Since DMR carries a high mortality, surgical correction, even in advanced age, constitutes the treatment of choice [3].We present the case of a female patient whose recent AMI was complicated by a combination of VSD and FWR of the LV with formation of a pseudoaneurysm, which were successfully surgically corrected. This case is interesting due to the scarcity of such reports and the authors wish to emphasize both the contributio
Fatal Huge Left Free Wall Ventricular Rupture after Acute Posterior Myocardial Infarction  [PDF]
Francesco Formica,Silvia Mariani,Orazio Ferro,Giovanni Paolini
Case Reports in Cardiology , 2013, DOI: 10.1155/2013/691971
Abstract: A 77-year-old man, with a recent history of an acute inferior myocardial infarction, was referred to our hospital with echocardiographic and clinical signs of left ventricular free wall rupture (LVFWR). The intraoperative finding demonstrated a huge double LVFWR. The inferoposterior wall was dramatically destroyed without any possibility to repair. Cardiac rupture represents a catastrophic complication of myocardial infarction with an incidence of 6% in the prereperfusion era [1]. In the reperfusion era, its incidence is between 1% and 3% of all myocardial infarction patients [2]. Despite significant improvement in the diagnosis and therapy of myocardial infarction, in-hospital death in patients complicated by cardiac rupture remains dramatically high. We describe the case of 77-year-old man who was admitted to peripheral hospital with chest pain and mild ST elevation on D2, D3, and aVF leads at the time of electrocardiogram admission. Diagnosis of acute posterior-inferior myocardial infarction was made, and the patient underwent prompt cardiac catheterization, which showed a proximally total occlusion of the right coronary artery. Due to initial symptoms of low cardiac output, a transthoracic echocardiogram was performed and pericardial effusion was detected. Therefore, the patient was referred to our hospital with echocardiographic and clinical signs of pericardial tamponade with the suspicion of left ventricular free wall rupture (LVFWR) to undergo emergently surgical repair. The patient arrived to our unit about 2 hours after initial symptoms. On arrival to operating room, the patient showed clinical signs of low cardiac output despite conventional therapy with inotropes and vasoconstrictor; the blood pressure was 80/50?mmHg, the pulse rate was 65 beats/min, the extremities were cold, and the urine output was less than 0.5?mL/Kg/min. The patient was promptly intubated and ventilated. A standard longitudinal sternotomy was performed, and the pericardium was opened. A fresh clot was observed over the inferior left ventricular wall. The systolic pressure dramatically raised, but suddenly a huge bleeding was observed into the pericardial cavity, and a pulseless ventricular tachycardia occurred. A sinus rhythm was obtained after internal DC shock at 7?Joule, cardiopulmonary bypass was established immediately, and the heart was arrested. The intraoperative finding showed a huge double LVFWR. One rupture was located in the territory of posterior descending artery for a length of about 6?cm (Figure 1, * mark), while the other rupture was located along the
Muerte súbita cardíaca en un paciente esquizofrénico: ruptura de la pared libre del ventrículo izquierdo por infarto agudo de miocardio: Exposición de un caso y revisión de la literatura Sudden cardiac death in a schizophrenic patient: left ventricular free wall rupture due to acute myocardial infarction: Case report and literature review  [cached]
A. Rico García,P.A. García Gallardo,J. Lucena Romero,A. Garfia González
Cuadernos de Medicina Forense , 2002,
Abstract: Los enfermos psiquiátricos, y concretamente los esquizofrénicos, manifiestan en ocasiones síntomas somáticos cuya interpretación es difícil lo que puede dar lugar a errores de diagnóstico diferencial con una patología orgánica. En el caso del infarto agudo de miocardio el error diagnóstico puede llegar a ser fatal con las lógicas repercusiones médico-forenses que se derivan de esta situación. En este artículo presentamos el caso de un paciente con un trastorno psiquiátrico perfectamente diagnosticado y tratado (esquizofrenia paranoide) asociado a una cardiopatía isquémica que debuta clínicamente con un infarto agudo de miocardio. No obstante, la sintomatología somática manifestada por el paciente fue atribuida a su proceso psicopatológico de base por lo que no se le prestó atención médica y se produjo el fallecimiento de forma súbita. En la autopsia médico-forense se encontró un taponamiento cardiaco secundario a la ruptura de la pared libre del ventrículo izquierdo por infarto agudo de miocardio. Se revisa la literatura sobre la ruptura de la pared libre del ventrículo izquierdo como complicación de un infarto agudo de miocardio atendiendo a sus características clínicas, frecuencia, factores de riesgo y anatomía patológica. Los estudios médico-forenses ponen de manifiesto que la frecuencia de esta complicación es muy superior cuando la muerte se produce en el medio extrahospitalario que cuando ocurre en el medio hospitalario. Psychiatric patients, mainly schizophrenics, have occasionally somatic symptoms that are difficult to interpret leading to errors in the differential diagnosis with an organic illness. In the case of the acute myocardial infarction, the diagnostic's mistake may be fatal with the logical medico-legal repercussions derived from this situation. In this paper we present the case of a patient with a mental disorder perfectly diagnosed and treated, (Paranoid Schizophrenia), associated with an ischemic cardiopathy which starts clinically with an acute myocardial infarction. However, the somatic symptoms where attributed to his mental disorder and no medical attention was demanded, leading to his sudden death. In the forensic autopsy a cardiac tamponade was found secondary to a left ventricular free wall rupture due to myocardial infarction. Medical literature about this complication of acute myocardial infarction is reviewed considering clinical aspects, frequency, risk factors and pathology. Medico-legal studies have shown that this complication is more frequent when the death occurs out-of-hospital as opposed of death occurring in-hosp
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