The additive role of cardiac CT in a patient with cardiogenic shock and suspected mechanical complication of myocardial infarction.

Abstract

A 69-year-old woman with previous hypertension and type-2 diabetes was admitted to the emergency department with syncope, referring continuous chest pain in the last 4 days. At hospital admission, the patient was in cardiogenic shock. The initial electrocardiogram showed Q waves in the anterior wall and ST-segment elevation on the anterior, lateral, and inferior walls. A bedside echocardiogram was immediately performed (panels A and B; Supplementary data online, Video S1) which showed a dilated left ventricle (LV) with severe LV systolic dysfunction and akynesia of the mid-apical segments of all ventricular walls. The patient had pericardial effusion (PE) with images suggesting clots near to the right ventricle free wall, with tamponade criteria. Although no rupture of the LV wall was clearly visible on echocardiogram, there was a high clinical suspicion of this complication. Cardiac computed tomography (CT) angiography confirmed myocardial rupture at the distal segment of the anterior wall and a mild circumferential PE, with a fluid density suggestive of haematic content (panels C, D, and E; Supplementary data online, Video S2). The patient underwent emergent surgery (panel F; Supplementary data online, Video S3) to correct the LV free wall rupture.