Abstract 18104: The Unexpected Disaster: Unusual Form of Left Ventricular Rupture

Abstract

Description: We present a 73-year-old female, who presented with NSTEMI. EKG showed ST depression in the inferior and anterior leads. Initial Troponin I was high (0.17 ng/mL). She received nitroglycerine with no relief of her pain, so she underwent an emergent left heart catheterization (LHC). The LHC showed two tandem 90% stenosis in the right coronary artery (RCA) and mild disease in the left anterior descending (LAD) and left circumflex (LCx) arteries. PCI to the RCA was successful. She was started on a high-intensity statin, carvedilol, dual antiplatelet therapy, and losartan. On the day after PCI, an echocardiogram showed preserved ejection fraction with no evidence of pericardial effusion. The patient was doing well until 2 days after the PCI when she was found obtunded and hypotensive. She received normal saline bolus, epinephrine, and norepinephrine, after which she improved. A bedside echocardiogram revealed evidence of pericardial effusion with tamponade physiology and a pericardial clot. The patient and her family declined further interventions and elected to proceed with comfort measures. Discussion: Mechanical complications of acute myocardial ischemia (AMI) have substantially decreased in numbers after the implication of early reperfusion therapies, but they remain fatal if not recognized early and treated. Free wall rupture (FWR) usually occurs in the first 7 days following an AMI, with an average of 2.6 days. FWR mostly happens after infarction of the LAD or LCx territories. In our case, there was no delay in reperfusion therapy and there was no evidence of infarction on the echocardiogram however the patient developed FWR as a complication and in a timeline earlier than average making this case unique.