Abstract
Left ventricular free wall rupture (LVFWR) is a fearful complication of acute myocardial infarction in which a swift diagnosis and emergency surgery can be crucial for successful treatment. Because a significant number of cases occur subacutely, clinicians should be aware of the risk factors, clinical features and diagnostic criteria of this complication. We report the case of a 69 year-old man in whom a subacute left ventricular free wall rupture (LVFWR) was diagnosed 7 days after an inferior myocardial infarction with late reperfusion therapy. An asymptomatic 3 to 5 mm saddle-shaped ST-segment elevation in anterior and lateral leads, detected on a routine ECG, led to an urgent bedside echocardiogram which showed basal inferior-wall akinesis, a small echodense pericardial effusion and a canalicular tract from endo to pericardium, along the interface between the necrotic and normal contracting myocardium, trough which power-Doppler examination suggested blood crossing the myocardial wall. A cardiac MRI further reinforced the possibility of contained LVFWR and a surgical procedure was undertaken, confirming the diagnosis and allowing the successful repair of the myocardial tear. This case illustrates that subacute LVFWR provides an opportunity for intervention. Recognition of the diversity of presentation and prompt use of echocardiography may be life-saving.
Highlights
Left ventricular free wall rupture (LVFWR) is a dramatic complication of acute myocardial infarction (AMI) and is presumably responsible for as much as 20 to 30% of all infarct related deaths [1,2,3,4]
The first clinical reference to post-infarction left ventricular wall rupture was reported by William Harvey in 1647 [6], but it wasn't until 1972 that Fitz Gibbon and Montegut conducted the first successful operation for the correction of LVFWR due to ischemic heart disease [7,8]
We describe the case of a 69 year-old patient with subacute "contained" LVFWR which was successfully treated through surgical correction
Summary
Left ventricular free wall rupture (LVFWR) is a dramatic complication of acute myocardial infarction (AMI) and is presumably responsible for as much as 20 to 30% of all infarct related deaths [1,2,3,4]. Electromechanical dissociation (with a diagnostic accuracy that reaches 97%) and bradycardia are features of the acute variety, while new ST-elevation in the affected leads or persistent non-inversion of T-waves may suggest the less noisy "stuttering" type of rupture [9,14] In this setting, interventions that can dramatically change prognosis can be employed, as long as an accurate diagnosis can be timely established. Despite rarely seen in the acute MI setting, cardiac tamponade may be caused by serous or serohaemorrhagic pericardial effusions; the risk of chamber puncture and the theoretical possibility of "thrombus displacement" and "decompression" of the contained rupture, can, hamper the diagnostic accuracy of pericardiocentesis, and make it potentially harmful Given these considerations, we strongly feel that this procedure should not be "routinely" used as a diagnostic tool and should be kept for situations of absolute need for tamponade relief [15]. Despite high perioperative mortality rates (33 to 55%), a rather well preserved post-procedure left ventricular function, as well as a fairly good functional long term prognosis are increasingly being reported [15,39,40,41]
Sign-in/Register to view highlights & summary 
Published Version (
Free)
Talk to us
Join us for a 30 min session where you can share your feedback and ask us any queries you have
Schedule a call