Abstract
Introduction: To present a rare occurrence of “Swiss-cheese” defects of left ventricle in acute myocardial infarction. Case Report: A 64-year-old male with persistent ST segment elevation in anterior and inferior leads developed sudden deterioration within 2 days after thrombolysis. Echocardiography revealed ventricular septal and LV (left ventricular) free wall ruptures at multiple sites with contractile dysfunction and the patient died suddenly, followed by an episode of ventricular tachycardia. Discussion: Myocardial rupture may complicate in 10% of acute myocardial infarctions and it is the second most common cause of in-hospital mortality next to pump failure. It is responsible for 15% of in-hospital deaths and 50% died within 5 days and 82% died within two weeks of index infarction. Conclusion: Aggressive early diagnosis and surgery may confer a survival rate as high as 75%. The prognosis is grave in patients presented with cardiogenic shock and multiorgan dysfunction; surgery is best avoided and supportive medical therapy may be adequate in such cases.
Highlights
To present a rare occurrence of “Swiss-cheese” defects of left ventricle in acute myocardial infarction
The middle layer of the left ventricle occupies the major portion of the myoarchitecture of the ventricular septum which forms the parietal wall of both right and left ventricle and it is lacking at the apical portion of the septum
Even though most of the ventricular ruptures occur in the free wall of the left ventricle [23], the rupture occurs in the interventricular septum in approximately 15% to 20% of cases [24] and it complicates 1% - 2% of acute myocardial infarction presentations in pre-thrombolytic era [25]
Summary
Left ventricular wall comprises three layers, superficial (subepicardial), middle, and deep (subendocardial) and the longitudinal alignment of myocardial strands of one layer interconnect with strands of layer in continuum, not separated by cleavage planes or sheets of fibrous tissue. The middle layer consists of circumferential strands and comprises 53% - 59% of ventricular wall thickness [1] It is thickest around the base, encircling the inlet and outlet portions and thinning out towards the cardiac apex. Cations such as cardiogenic shock occurs in 50 % of cases [8] This can lead to left ventricular rupture and recent studies reported right ventricular involvement in 28% - 50% [9] [10], the friable right ventricle susceptible to rupture due to mechanical wall stress in biventricular Takotsubo cardiomyopathy [11]. Multiple sites of rupture in the left ventricular myocardium including the interventricular septum following an acute myocardial infarction are uncommon and so this case had been reported
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