A CASE REPORT

Post-infarction left ventricular free wall rupture

Dr Thai Minh Nguyen

Hanoi Heart Hospital

INTRODUCTION

- MECHANICAL COMPLICATION AMI

- 1-3%

- UNDIAGNOSED

- MORTALITY 60-80%

Factors related to heart rupture in acute coronary syndromes in the Global Registry of Acute Coronary Events. José López-Sendón,

Enrique P. Gurfinkel, Esteban Lopez de Sa, Giancarlo Agnelli, Joel M. Gore, Phillippe Gabriel Steg, Kim A. Eagle, Jose Ruiz Cantador, Gordon

Fitzgerald, Christopher B. Granger, et al.Eur Heart J. 2010 Jun; 31(12): 1449–1456

Shamshad F, Kenchaiah S, Finn PV, Soler-Soler J, McMurray JJ, Velazquez EJ et al. Fatal myocardial rupture after acute myocardial infarction

complicated by heart failure, left ventricular dysfunction, or both: the VALsartan In Acute myocardial iNfarcTion Trial (VALIANT). Am

Heart J 2010;160:145–51.

PATIENT REPORT

79 yo-man Taiwanese

Medical history HBP

Retrosternal chest pain 2 d, no treatment

Admitted: Syncope

Unconscious

P 105; BP 60/40

Auscultation No systolic murmur

ECG: → No ST Elevation

TTE

Pericardial perfusion

Tamponade: RA,RV

diast collapse

CLINICAL PRESENTATION

- pericardial bleeding & consequent pericardial tamponade

- 1-7 days post AMI

- Many cases die within few minutes

1.Abdelnaby M, et al. Post-myocardial Infarction Left Ventricular Free Wall Rupture: Review article. Ann Med Health Sci Res. 2017; 7: 368-372

2.Oliva PB Cardiac rupture, a clinically predictable complication of acute myocardial infarction: Report of 70 cases with clinicopathologic correlation.

Journal of the American College of Cardiology, 1993. 22: p. 720-26.

CLINICAL PRESENTATION

- RISK FACTOR

- AGE > 55 (65-70)

- FEMALE

- 1st AMI : anterior/ lateral (collateral circ)

- Killip I,II

- Late/ fail thrombolysis or pci

- TRIGGERING FACTOR : BP >150 1ST 24H , UNDUE PHYSICAL EFFORT( PERSISTENT COUGHING, VOMITING, AGITATION…)

- PRODROMAL MANIFESTATIONS : PERSISTENT CHEST PAIN, INTRACTABLE VOMITING,

RESTLESSNESS, PERSISTENT S-T SEGMENT ELEVATION, AND POSITIVE T WAVE DEFLECTION

PERSISTS FOR 72 HOURS.

1.Abdelnaby M, et al. Post-myocardial Infarction Left Ventricular Free Wall Rupture: Review article. Ann Med Health Sci Res. 2017; 7: 368-372

2.Oliva PB Cardiac rupture, a clinically predictable complication of acute myocardial infarction: Report of 70 cases with clinicopathologic correlation.

Journal of the American College of Cardiology, 1993. 22: p. 720-26.

DIAGNOSTIC TESTS

TTE: gold standard

MSCT: beneficial in cases

diagnosis is doubtful /exclude

other causes of

hemopericardium such as

aortic dissection

MRI: no in acute phase

Angio: no in acute phase

Offer Amir, R.S., Akaira Nishikawa, et al, Left Ventricular Free Wall Rupture in Acute

Myocardial Infarction Tex Heart Inst J, 2005. 32: p. 424-26.

AMI + hemodynamic collapse

TTE: hemopericardium +/- right-

sided heart collapse

Cardiac rupture

SUSPECTED DIAGNOSIS

Type A acute aortic

dissectionLVFWR post AMI

CK-MB; Troponin

Echocard

Waiting?

MS CT scan ?

EMERGENCY SURGERY

BRIDGE TO EMERGENCY SURGERY

Matteucci, M(2019) Treatment strategies for post-infarction left ventricular free-wall rupture. Eur Heart J Acute Cardiovasc

PERICARDIOCENTESIS

Caterina Chiara De Carlini, (2017): Pericardiocentesis in cardiac tamponade: indications and practical aspects, ESC Vol. 15, N° 19 - 11

AFTER PERICARDIOCENTESIS

- Became conscious

- HR 85; BP 100/60

- ECG: still not significant

- CK-MB 107; Troponin Ths: 1832

- TTE re-checked: LVEF 70%, hypokinesis of lateral wall of LV, no hemopericardium

- MSCT: No evidence of aortic dissection

→ LVFWR confirmed

CLASSIFICATION OF

LVFWR

Acute: die quickly 2/3

Subacute: 1/3

Chronic: pseudoaneurysm

Morphological:

4 type: ‘tear’

‘Blow-out’ ‘Oozing’

Type I Type II Type III Type IV

30 MINUTES AFTER PERICARDIOCENTESIS

Regained shock, cardiac arrest rapidly

His family accept to operation

Surgical group ready

→ CPR → automated CPR machine → Operating Room

OPERATION

- Femorofemoral bypass

- Sternotomy

- 400ml blood+ clot

- ‘Tear’ 2cm continu bleeding

- Xclamp

- Anterograde cardioplegia Custodiol

SURGICAL REPAIR

Aime: quickly relieving of tamponade + closure of ventricular wall defect

4 technique:

1: Direct closure

II resection of the infarction region + closure of the deficit with separate Teflon

reinforced sutures

III: horizontal continuous suture of the lesion, reinforced with double Teflon layer

IV: gluing of Teflon patch or of bovine pericardium on the lesion and the area with

necrosis (oozing rupture)

II III IV

ADDITIVE CABG???

2 opinion:

Not recommend:1

Waste time

main purpose of surgery not revascularization → perform later

Not always have preoperative coronarography, the effectiveness not yet demonstrated

Recommend2,3,4

80% LVFWR multi-vessel disease → should perform

Improve long-term, avoid the risk of repeat infarction in the early postoperative period

1, Martin H. (2001)Surgical Experience With Left Ventricular Free Wall Rupture Ann Thorac Surg

2, Matteucci, M.(2019), Treatment strategies for post-infarction left ventricular free-wall rupture. Eur Heart J Acute Cardiovasc Care

3, Formica F(2018) Postinfarction left ventricular free wall rupture: a 17-year single-centre experience. Eur J Cardiothorac Surg

4, Abdelnaby M, (2017) Post-myocardial Infarction Left Ventricular Free Wall Rupture: Review article. Ann Med Health Sci Res

CABG IN OUR CASE

No coronarography

On ‘Touch’ peroperative:

severe calcification in RA and proximal LAD

culprit OMs-LCx : time >48h, which exact culprit OMs

→ severe 3 vessel disease??? → 2CBGA to LAD+ PDA

MANAGEMENT IN

ICU

No IABP, No ECMO

Renal failure need

Hemodialysis 8 d

Pneumonia → antibiotic

treatment

Extubated 10 d

TTE: good LVEF, no dyskinesis

of LV’s wall.

Discharged 14 d

Matteucci, M(2019) Treatment strategies for post-infarction left ventricular free-wall rupture. Eur Heart J Acute Cardiovasc

POST-OPERATIVE CORONAROGRAPHY

CONCLUSION

LVFWR is catastrophic complication of AMI but unpredictable

To diagnose: AMI + hymodynamic collapse → TTE (hemopericardium) → LVFWR

Pericardiocentecis may be benefit as a bridge to emergency surgery

Close coordination between groups to early diagnose and to transfer the patient to OR as soon as possible

CABG may be helpful to improve the patient’s outcome

This case demonstrates that left ventricular free wall rupture is not always fatal