The Broken Heart

Abstract

HomeCirculationVol. 123, No. 18The Broken Heart Free AccessBrief ReportPDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toFree AccessBrief ReportPDF/EPUBThe Broken Heart Bernhard Petritsch, MD, Frank Wendel, MD, Rainer G. Leyh, MD and Stefan Frantz, MD Bernhard PetritschBernhard Petritsch From the Medizinische Klinik und Poliklinik I, Herzkreislauf-Zentrum (S.F.); Institut für Röntgendiagnostik (B.P., F.W.) and Department of Cardiac, Thoracic, and Thoracic Vascular Surgery (R.G.L.), Universität Würzburg, Würzburg, Germany. Search for more papers by this author , Frank WendelFrank Wendel From the Medizinische Klinik und Poliklinik I, Herzkreislauf-Zentrum (S.F.); Institut für Röntgendiagnostik (B.P., F.W.) and Department of Cardiac, Thoracic, and Thoracic Vascular Surgery (R.G.L.), Universität Würzburg, Würzburg, Germany. Search for more papers by this author , Rainer G. LeyhRainer G. Leyh From the Medizinische Klinik und Poliklinik I, Herzkreislauf-Zentrum (S.F.); Institut für Röntgendiagnostik (B.P., F.W.) and Department of Cardiac, Thoracic, and Thoracic Vascular Surgery (R.G.L.), Universität Würzburg, Würzburg, Germany. Search for more papers by this author and Stefan FrantzStefan Frantz From the Medizinische Klinik und Poliklinik I, Herzkreislauf-Zentrum (S.F.); Institut für Röntgendiagnostik (B.P., F.W.) and Department of Cardiac, Thoracic, and Thoracic Vascular Surgery (R.G.L.), Universität Würzburg, Würzburg, Germany. Search for more papers by this author Originally published10 May 2011https://doi.org/10.1161/CIRCULATIONAHA.110.988121Circulation. 2011;123:2020–2021A 50-year-old woman presented to the intensive care unit with a subacute inferior ST-segment elevation myocardial infarction. Her last chest pain was 2 days before. At the time of admission, she was in no distress, and was hemodynamically stable. Inferior ST-segment elevations and Q waves were documented on the initial ECG (Figure 1). Laboratory data showed signs of a subacute myocardial infarction as well as acute renal failure. On echocardiography, a small inferior wall motion abnormality could be seen with little pericardial effusion, which was not clearly suggestive of a hemorrhagic effusion (Movie I in the online-only Data Supplement). Initial computed tomography (Figure 2A) of the chest confirmed a circumferential pericardial effusion of 1.5-cm thickness and between ≈10 and 17 Hounsfield units, consistent with a serous effusion. Thus, pericardial effusion was interpreted as Dressler's syndrome.Download figureDownload PowerPointFigure 1. ECG. The initial ECG showed Q waves and ST-segment elevations in the inferior leads.Download figureDownload PowerPointFigure 2. Computed tomography of left ventricular rupture after subacute myocardial infarction. After subacute myocardial infarction, a pericardial effusion was detected on echocardiography and interpreted as serous effusion on computed tomography (A). Twenty hours later, hemodynamic instability developed. Contrast-enhanced multislice computed tomography showed inferior and papillary ischemia (B; black arrow). Contrast spilling in the pericardium indicated left ventricular rupture (B through D; white arrow).On the next day, acute dyspnea and cardiac shock developed, and the patient was intubated and put on vasopressors. The ECG and pericardial effusion on echocardiography were unchanged. A second contrast-enhanced computed tomographic scan of the chest was performed, and revealed a large hypodense nonenhancing myocardial infarction of the left ventricular posterior wall and a hypodense nonenhancing papillary muscle (Figure 2B). The multislice computed tomographic scan clearly depicted a transmural fissural rupture (type I) of the inferior left ventricular wall within the area of infarction and spilling of contrast medium into the pericardium (Figure 2B through 2D). The pericardial effusion was progressive in volume and showed mixed density values, with denser areas (36 to 40 Hounsfield units) consistent with a hemorrhagic effusion and areas of lower density (18 to 20 Hounsfield units) matching coagulated blood. Rupture of the inferior left ventricle could be confirmed on a ventriculogram (Figure 3 and Movies II and III in the online-only Data Supplement). The myocardial infarction was due to closure of the circumflex artery. The patient underwent surgery immediately. Hemorrhagic effusion due to rupture of the lateral wall was confirmed and surgically corrected. However, the patient died 3 days later in cardiogenic shock.Download figureDownload PowerPointFigure 3. Ventriculogram of left ventricular rupture. In the immediately performed coronary angiography and angiogram, effusion of contrast media (arrow) in the pericardium was detected.Myocardial rupture is the most severe complication of acute coronary syndrome, with high mortality. According to a recent report of the Global Registry of Acute Coronary Events, the frequency of myocardial rupture is 0.45% of all myocardial infarctions.1,2DisclosuresNone.FootnotesThe online-only Data Supplement is available with this article at http://circ.ahajournals.org/cgi/content/full/CIRCULATIONAHA.110.988121/DC1.Correspondence to Stefan Frantz, MD, Medizinische Klinik und Poliklinik I, Universitätsklinikum Würzburg, Oberdürrbacher Strasse 6, 97080 Würzburg, Germany. E-mail [email protected]uni-wuerzburg.de