Left Ventricular Free Wall Rupture and Contained Pseudoaneurysm Formation in a Patient with Prior Coronary Artery Bypass Graft

Abstract

An 87-year-old male with prior coronary artery bypass grafts (CABG) presented to hospital with a NSTEMI and peak TnI 7.6 μg/L. A drug-eluting stent was placed in the mid left anterior descending artery beyond the anastomosis of the left internal mammary artery graft. He was discharged at day 5, his echocardiogram showing akinesis of his anterolateral wall. Three days later the patient developed sudden chest pain after heavily exerting himself lawn-mowing. On arrival, his pain had resolved spontaneously, he was haemodynamically stable with no new EKG changes but TnI was 15 μg/L. Repeat coronary angiography excluded in-stent thrombosis, no ventriculogram was performed. He remained asymptomatic but on day 3 repeat echocardiogram revealed a new cavity adjacent to the left ventricle (LV) with bi-directional doppler flow. CT coronary angiogram defined a contained free wall rupture of the LV measuring 10 × 9x4.3 cm. LV free wall rupture is an uncommon but life threatening complication of ST-elevation myocardial infarction. While there are case reports describing ‘oozing’ or sub-acute rupture, we can find no case reports detailing an asymptomatic free wall rupture with an organised cavity in the setting of recent NSTEMI and previous CABG. We hypothesise that chronic adhesions between the epicardium and parietal pericardium from prior CABG formed a pseudoaneurysm preventing haemodynamic compromise. In unstable patients, urgent surgical intervention is usually the only feasible option. Our patient had been haemodynamically stable with no further chest pain following re-presentation. Following detailed multi-disciplinary team discussions with the patient his informed decision was to decline surgery.