© 2014, Wiley Periodicals, Inc. DOI: 10.1111/echo.12727
Echocardiography
Lateral Left Ventricular Wall Rupture Following Acute Myocardial Infarction: Pathophysiological Interpretation by Multimodality Imaging Approach Gustavo Avegliano, M.D., Ph.D., Diego Conde, M.D., Marıa Isabel Gonz alez Ruiz, M.D., Paola Kuschnir, M.D., Agustina Sciancalepore, M.D., Florencia Castro, M.D., and Ricardo Ronderos, M.D., Ph.D. Cardiovascular Institute of Buenos Aires, Buenos Aires, Argentina
Lateral left ventricular wall rupture (LVWR) is a rare complication following acute myocardial infarction (AMI) less than 1%. After cardiogenic shock, LVWR constitutes the most common cause of in-hospital death in AMI patients. Around 40% of all LVWR occurred during the first 24 hours and 85% within the first week. In the present case, 76 hours following the intervention, LVWR was observed likely due to a small infarction at the lateral left ventricular wall possibly due to the marginal lesion. Our patient refused surgery and was followed clinically. Eighteen months later, real time three-dimensional echocardiography showed a pseudoaneurysm. (Echocardiography 2014;31:E296–E299) Key words: ventricular wall rupture, acute myocardial infarction, echocardiogram, multimodality imaging Lateral left ventricular wall rupture (LVWR) is a rare complication following acute myocardial infarction (AMI) less than 1%, reaching 10–25% in autopsy of AMI patients. After cardiogenic shock, LVWR constitutes the most common cause of in-hospital death in AMI patients. Around 40% of all LVWR occurred during the first 24 hours and 85% within the first week. It is frequently associated with advanced age, female gender, systemic arterial hypertension, absence of preinfarction angina, and no visible collaterals during catheterization. Diagnosis is suspected in patients with severe hypotension, extreme bradycardia, or cardiac arrest with electrical mechanical dissociation. Rupture is confirmed with echocardiographic evidence of a large pericardial effusion, with echoes suggestive of hemopericardium. As in the present case, patients with prior history of cardiac surgery may experience self-limited myocardial rupture with prompt sealing due to pericardial adhesions, resulting into a pseudoaneurysm. The development of a pseudoaneurysm after an AMI is exceedingly low and its natural evolution is unknown.1–8 Case: The patient is a smoker, with a long-standing history of coronary artery disease and surgical Address for correspondence and reprint requests: Gustavo Avegliano, M.D., Ph.D., Blanco Encalada 1543, Buenos Aires 1428, Argentina. Fax: +54 11 4787 7500 (ext. 3166); E-mail: [email protected]
E296
myocardial revascularization (left internal mammary artery to left anterior descending coronary artery and a vein graft to right coronary artery) 10 years prior to this admission. At this admission, he initially suffered a non–ST segment elevation myocardial infarction with a positive value of troponin I (Table I) and cardiac catheterization, performed the first day, showed significant lesions of first diagonal and first marginal coronary arteries branches. Both arteries were stented. The ST segment elevation myocardial infarction occurred after 76 hours of the intervention (period in which the patient remained asymptomatic), when he had a syncopal episode associated with severe bradycardia, followed by chest pain. We made a new coronary angiography without significant lesions. (Fig. 1). Thus, we interpreted that the rupture of the lateral left ventricular wall, visible in the transthoracic echocardiogram (TTE) (Philips iE33 with a S5-1 transducer, Philips Medical Systems, Bothell, WA, USA), real time three-dimensional echocardiography (RT3DE) (Philips iE33), and magnetic resonance imaging was a structural complication of AMI (Fig. 2) (movie clips S1–S14). Full-volume images were acquired with ECG gating using the 4-beat modality with a 10-second breath-hold. The images were stored for subsequent processing. The analysis was made using the commercially available software QLab 9.0 (Philips Medical Systems).
Lateral Left Ventricular Wall Rupture
TABLE I Values of Troponin I (4th Generation) Normal Value
Admission
24 Hours
Post PCI
Syncopal Episode
Pseudoaneurysm Diagnosis (after 2nd Cardiac Catheterization)
0.01–0.5 lg/L
0.06
12.46
8.6
3.24
10.1
PCI = percutaneous coronary intervention.
Figure 1. ECG A. with and B. without ST elevation.
Conclusions: In the present case, 76 hours following the intervention, lateral LVWR was observed likely due to a small infarction at the lateral left ventricular wall, possibly secondary to the marginal coronary artery lesion. Our patient refused surgery and was followed up clinically. Eighteen months later, RT3DE showed a pseudoaneurysm. Usually, bidimensional and contrast TTE are enough for clinical diagnosis purposes. But, on the other hand, RT3DE gives greater anatomical and functional information complementary to TTE and appears as an exceptional imaging tool prior to intervention both surgical and percuta-
neous. The RT3DE helps to determine the precise anatomy of the myocardial defect and its spatial relationship with adjacent structures such as mitral subvalvular apparatus, thus helping to define the possibility to proceed with a percutaneous closure device. Moreover, the morphological characterization of myocardial defect and its accurate measurement, contribute to appropriate device selection. The combination of different cardiac imaging modalities undoubtedly improves the diagnostic accuracy as well as the physiopathological interpretation to make the most accurate diagnosis and the best clinical decision for therapy. E297
Avegliano, et al.
Figure 2. Multimodality imaging approach. A. TTE (acute phase). Note the rupture at the mid-portion of the lateral left ventricular wall (arrow) and a localized pericardial effusion adjacent to the lateral wall. B. Contrast TTE. Note contrast filling of the pericardium and opacification of a parallel cavity, in relation to the left ventricle, with systolic and diastolic flow through the rupture. C. MRI. Left: Cine-MRI (SSFP) at four-chamber view. Note the LVWR (arrow) and localized pericardial effusion. D. Delayed enhancement-MRI (inversion-recovery) following gadolinium administration. Presence of thrombotic pericardial adhesions in the apical region (dashed arrow). Absence of late enhancement (related to the complete loss of tissue compatible with a small transmural myocardial infarction). E. RT3DE performed at 18 months from the event. Full ventricular volume image revealing a pseudoaneurysm and the rupture area at the mid-portion of the left lateral ventricular wall. F. Three-dimensional echocardiogram. Full 3D volume processed image. View from of the lateral wall from the pseudoaneurysm (the darkest area demarcated by the arrows indicates the rupture area). G. The same view with color flow Doppler during diastole, note 3 small points suggesting the flow goes through the rupture wall to the LV cavity in diastole. TTE = transthoracic echocardiography; MRI = magnetic resonance imaging; RT3DE = real time three-dimensional echocardiography; LV = left ventricle; LA = left atrium; RA = right atrium; IVS = interventricular septum; LW = lateral wall; PA = pseudoaneurysm; VFWR = ventricular free wall rupture; PE = pericardial effusion.
References
pez-Sendo n J, Gonzalez A, Lo pez de Sa E, et al: Diagno1. Lo sis of subacute ventricular wall rupture after acute myocardial infarction: Sensitivity and specificity of clinical, hemodynamic and echocardiographic criteria. J Am Coll Cardiol 1992;19:1145–1153. 2. Biorck G, Mogensen L, Nyquist O, et al: Studies of myocardial rupture with tamponade in acute myocardial infarction: Clinical features. Chest 1972;61:4–6. pez S pez-Sendo n JL, Rubio R: Infarto agudo de 3. de Lo a E, Lo n y complicaciones. In: Delcan miocardio: Clınica, evolucio JL (ed): Cardiopatıa isque mica. Madrid: ENE ediciones, 1999, pp. 583–584. 4. Figueras J, Cortadellas J, Calvo F, et al: Relevance of delayed hospital admission on development of cardiac rupture during acute myocardial infarction: Study in 225 patients with free wall, septal or papillary muscle rupture. J Am Coll Cardiol 1998;32:135–139. 5. Oliva PO, Hammill SC, Edwards WE: Cardiac rupture, a clinically predictable complication of acute myocardial infarction: Report of 70 cases with clinic pathologic correlations. J Am Coll Cardiol 1993;22:720–726. 6. Pappas PJ, Cernainau AC, Baldino WA, et al: Ventricular free wall rupture after myocardial infarction: Treatment and outcome. Chest 1991;99:892–895. 7. Figueras J, Soler Soler J: Rotura Cardiaca Isquemica. Barce n, 2001. lona: Doyma Publicacio
E298
8. Pires de Morais G, Paulo N, Vieira MS, et al: Complex ventricular septal rupture with dissection of the right ventricular wall in ischemic context. Echocardiography 2012;29: E112–E114.
Supporting Information Additional Supporting Information may be found in the online version of this article: Movie clip S1. TTE (acute phase). Twodimensional, apical five-chamber view. Note the rupture at the mid-portion of the lateral left ventricular wall (arrow) and a localized pericardial effusion adjacent to the lateral wall. PC = pericardial cavity; RV = right ventricle; LV = left ventricle; LA = left atrium. The arrow indicates the rupture zone. Movie clip S2. TTE. Four-chamber view with color Doppler. Note how the passage of flow occurs in systole from the left ventricle into the pericardial cavity and in diastole, returning from the pericardial sac into the left ventricle. PC = pericardial cavity; RV = right ventricle;
Lateral Left Ventricular Wall Rupture
LV = left ventricle; LA = left atrium; RA = right atrium. The arrow indicates the rupture zone. Movie clip S3. TTE. Zoom with of the lateral wall at rupture level with color Doppler. Note the systolic and diastolic flow between the left ventricular cavity and the pericardial sac. PC = pericardial cavity; LV = left ventricle. The arrow indicates the rupture zone. Movie clip S4. Contrast TTE. Four-chamber view loop. Note contrast filling of the pericardium and opacification of a parallel cavity, in relation to the left ventricle, with systolic and diastolic flow through the rupture. PC = pericardial cavity, LV = left ventricle; LA = left atrium; LW = lateral wall. The arrow indicates the rupture zone. Movie clip S5. Cardiac magnetic resonance (CMR). Cine-sequence (SSFP) at short-axis view. Note the LVWR (arrow) and localized pericardial effusion. PC = pericardial cavity; LV = left ventricle. The arrow indicates the rupture zone. Movie clip S6. CMR. Cine-sequence (SSFP) at short-axis view. Note the LVWR (arrow) and localized pericardial effusion. PC = pericardial cavity; LV = left ventricle. The arrow indicates the rupture zone. Movie clip S7. CMR. Cine-sequence (SSFP) at four-chamber view. Note the LVWR (arrow) and localized pericardial effusion. PC = pericardial cavity; RV = right ventricle; LV = left ventricle; LA = left atrium; RA = right atrium. The arrow indicates the rupture zone. Movie clip S8. CMR. Cine-sequence (SSFP) at five-chamber view. Note the LVWR (arrow) and localized pericardial effusion. PC = pericardial cavity; RV = right ventricle; LV = left ventricle; LA = left atrium; RA = right atrium. The arrow indicates the rupture zone.
Movie clip S9. 3DTTE. 3D full volume cropped image. View from the lateral wall perspective. This loop reveals a pseudoaneurysm and the rupture area at the mid-potion of the left lateral ventricular wall (arrow). LW = lateral wall; LV = left ventricle; LA = left atrium; VPS = ventricular pseudoaneurysm. Movie clip S10. 3DTTE. 3D full volume cropped image. View from the lateral wall perspective. Contrast concentration is greater in LV cavity and there is a clear transit of contrast from cavity to the pseudoaneurysm through the rupture left ventricular wall. LW = lateral wall; LV = left ventricle; LA = left atrium; VPS = ventricular pseudoaneurysm. Movie clip S11. 3DTTE. 3D full volume cropped image in a longitudinal plane. View from the pseudoaneurysm perspective lateral wall perspective pointing out the anatomy of the pseudoaneurysm along the lateral wall from the base to the apex of the heart. LV = left ventricle; LA = left atrium. VPS = ventricular pseudoaneurysm. Movie clip S12. 3DTTE. 3D full volume cropped image in a transversal plane. View from the apex to the base of the LV at the level of lateral wall rupture. Pseudoaneurysm sac shows systolic expansion. LV = left ventricle; VPS = ventricular pseudoaneurysm. Movie clip S13. 3DTTE. 3D full volume processed image with color focusing the lateral wall. Movie clip S14. 3DTTE. 3D full volume postprocessed image with color Doppler. View of the lateral wall from the pseudoaneurysm with color flow Doppler. Note 3 small points that allow the morphological characteristic of the lateral wall rupture.
E299
Echocardiography
Lateral Left Ventricular Wall Rupture Following Acute Myocardial Infarction: Pathophysiological Interpretation by Multimodality Imaging Approach Gustavo Avegliano, M.D., Ph.D., Diego Conde, M.D., Marıa Isabel Gonz alez Ruiz, M.D., Paola Kuschnir, M.D., Agustina Sciancalepore, M.D., Florencia Castro, M.D., and Ricardo Ronderos, M.D., Ph.D. Cardiovascular Institute of Buenos Aires, Buenos Aires, Argentina
Lateral left ventricular wall rupture (LVWR) is a rare complication following acute myocardial infarction (AMI) less than 1%. After cardiogenic shock, LVWR constitutes the most common cause of in-hospital death in AMI patients. Around 40% of all LVWR occurred during the first 24 hours and 85% within the first week. In the present case, 76 hours following the intervention, LVWR was observed likely due to a small infarction at the lateral left ventricular wall possibly due to the marginal lesion. Our patient refused surgery and was followed clinically. Eighteen months later, real time three-dimensional echocardiography showed a pseudoaneurysm. (Echocardiography 2014;31:E296–E299) Key words: ventricular wall rupture, acute myocardial infarction, echocardiogram, multimodality imaging Lateral left ventricular wall rupture (LVWR) is a rare complication following acute myocardial infarction (AMI) less than 1%, reaching 10–25% in autopsy of AMI patients. After cardiogenic shock, LVWR constitutes the most common cause of in-hospital death in AMI patients. Around 40% of all LVWR occurred during the first 24 hours and 85% within the first week. It is frequently associated with advanced age, female gender, systemic arterial hypertension, absence of preinfarction angina, and no visible collaterals during catheterization. Diagnosis is suspected in patients with severe hypotension, extreme bradycardia, or cardiac arrest with electrical mechanical dissociation. Rupture is confirmed with echocardiographic evidence of a large pericardial effusion, with echoes suggestive of hemopericardium. As in the present case, patients with prior history of cardiac surgery may experience self-limited myocardial rupture with prompt sealing due to pericardial adhesions, resulting into a pseudoaneurysm. The development of a pseudoaneurysm after an AMI is exceedingly low and its natural evolution is unknown.1–8 Case: The patient is a smoker, with a long-standing history of coronary artery disease and surgical Address for correspondence and reprint requests: Gustavo Avegliano, M.D., Ph.D., Blanco Encalada 1543, Buenos Aires 1428, Argentina. Fax: +54 11 4787 7500 (ext. 3166); E-mail: [email protected]
E296
myocardial revascularization (left internal mammary artery to left anterior descending coronary artery and a vein graft to right coronary artery) 10 years prior to this admission. At this admission, he initially suffered a non–ST segment elevation myocardial infarction with a positive value of troponin I (Table I) and cardiac catheterization, performed the first day, showed significant lesions of first diagonal and first marginal coronary arteries branches. Both arteries were stented. The ST segment elevation myocardial infarction occurred after 76 hours of the intervention (period in which the patient remained asymptomatic), when he had a syncopal episode associated with severe bradycardia, followed by chest pain. We made a new coronary angiography without significant lesions. (Fig. 1). Thus, we interpreted that the rupture of the lateral left ventricular wall, visible in the transthoracic echocardiogram (TTE) (Philips iE33 with a S5-1 transducer, Philips Medical Systems, Bothell, WA, USA), real time three-dimensional echocardiography (RT3DE) (Philips iE33), and magnetic resonance imaging was a structural complication of AMI (Fig. 2) (movie clips S1–S14). Full-volume images were acquired with ECG gating using the 4-beat modality with a 10-second breath-hold. The images were stored for subsequent processing. The analysis was made using the commercially available software QLab 9.0 (Philips Medical Systems).
Lateral Left Ventricular Wall Rupture
TABLE I Values of Troponin I (4th Generation) Normal Value
Admission
24 Hours
Post PCI
Syncopal Episode
Pseudoaneurysm Diagnosis (after 2nd Cardiac Catheterization)
0.01–0.5 lg/L
0.06
12.46
8.6
3.24
10.1
PCI = percutaneous coronary intervention.
Figure 1. ECG A. with and B. without ST elevation.
Conclusions: In the present case, 76 hours following the intervention, lateral LVWR was observed likely due to a small infarction at the lateral left ventricular wall, possibly secondary to the marginal coronary artery lesion. Our patient refused surgery and was followed up clinically. Eighteen months later, RT3DE showed a pseudoaneurysm. Usually, bidimensional and contrast TTE are enough for clinical diagnosis purposes. But, on the other hand, RT3DE gives greater anatomical and functional information complementary to TTE and appears as an exceptional imaging tool prior to intervention both surgical and percuta-
neous. The RT3DE helps to determine the precise anatomy of the myocardial defect and its spatial relationship with adjacent structures such as mitral subvalvular apparatus, thus helping to define the possibility to proceed with a percutaneous closure device. Moreover, the morphological characterization of myocardial defect and its accurate measurement, contribute to appropriate device selection. The combination of different cardiac imaging modalities undoubtedly improves the diagnostic accuracy as well as the physiopathological interpretation to make the most accurate diagnosis and the best clinical decision for therapy. E297
Avegliano, et al.
Figure 2. Multimodality imaging approach. A. TTE (acute phase). Note the rupture at the mid-portion of the lateral left ventricular wall (arrow) and a localized pericardial effusion adjacent to the lateral wall. B. Contrast TTE. Note contrast filling of the pericardium and opacification of a parallel cavity, in relation to the left ventricle, with systolic and diastolic flow through the rupture. C. MRI. Left: Cine-MRI (SSFP) at four-chamber view. Note the LVWR (arrow) and localized pericardial effusion. D. Delayed enhancement-MRI (inversion-recovery) following gadolinium administration. Presence of thrombotic pericardial adhesions in the apical region (dashed arrow). Absence of late enhancement (related to the complete loss of tissue compatible with a small transmural myocardial infarction). E. RT3DE performed at 18 months from the event. Full ventricular volume image revealing a pseudoaneurysm and the rupture area at the mid-portion of the left lateral ventricular wall. F. Three-dimensional echocardiogram. Full 3D volume processed image. View from of the lateral wall from the pseudoaneurysm (the darkest area demarcated by the arrows indicates the rupture area). G. The same view with color flow Doppler during diastole, note 3 small points suggesting the flow goes through the rupture wall to the LV cavity in diastole. TTE = transthoracic echocardiography; MRI = magnetic resonance imaging; RT3DE = real time three-dimensional echocardiography; LV = left ventricle; LA = left atrium; RA = right atrium; IVS = interventricular septum; LW = lateral wall; PA = pseudoaneurysm; VFWR = ventricular free wall rupture; PE = pericardial effusion.
References
pez-Sendo n J, Gonzalez A, Lo pez de Sa E, et al: Diagno1. Lo sis of subacute ventricular wall rupture after acute myocardial infarction: Sensitivity and specificity of clinical, hemodynamic and echocardiographic criteria. J Am Coll Cardiol 1992;19:1145–1153. 2. Biorck G, Mogensen L, Nyquist O, et al: Studies of myocardial rupture with tamponade in acute myocardial infarction: Clinical features. Chest 1972;61:4–6. pez S pez-Sendo n JL, Rubio R: Infarto agudo de 3. de Lo a E, Lo n y complicaciones. In: Delcan miocardio: Clınica, evolucio JL (ed): Cardiopatıa isque mica. Madrid: ENE ediciones, 1999, pp. 583–584. 4. Figueras J, Cortadellas J, Calvo F, et al: Relevance of delayed hospital admission on development of cardiac rupture during acute myocardial infarction: Study in 225 patients with free wall, septal or papillary muscle rupture. J Am Coll Cardiol 1998;32:135–139. 5. Oliva PO, Hammill SC, Edwards WE: Cardiac rupture, a clinically predictable complication of acute myocardial infarction: Report of 70 cases with clinic pathologic correlations. J Am Coll Cardiol 1993;22:720–726. 6. Pappas PJ, Cernainau AC, Baldino WA, et al: Ventricular free wall rupture after myocardial infarction: Treatment and outcome. Chest 1991;99:892–895. 7. Figueras J, Soler Soler J: Rotura Cardiaca Isquemica. Barce n, 2001. lona: Doyma Publicacio
E298
8. Pires de Morais G, Paulo N, Vieira MS, et al: Complex ventricular septal rupture with dissection of the right ventricular wall in ischemic context. Echocardiography 2012;29: E112–E114.
Supporting Information Additional Supporting Information may be found in the online version of this article: Movie clip S1. TTE (acute phase). Twodimensional, apical five-chamber view. Note the rupture at the mid-portion of the lateral left ventricular wall (arrow) and a localized pericardial effusion adjacent to the lateral wall. PC = pericardial cavity; RV = right ventricle; LV = left ventricle; LA = left atrium. The arrow indicates the rupture zone. Movie clip S2. TTE. Four-chamber view with color Doppler. Note how the passage of flow occurs in systole from the left ventricle into the pericardial cavity and in diastole, returning from the pericardial sac into the left ventricle. PC = pericardial cavity; RV = right ventricle;
Lateral Left Ventricular Wall Rupture
LV = left ventricle; LA = left atrium; RA = right atrium. The arrow indicates the rupture zone. Movie clip S3. TTE. Zoom with of the lateral wall at rupture level with color Doppler. Note the systolic and diastolic flow between the left ventricular cavity and the pericardial sac. PC = pericardial cavity; LV = left ventricle. The arrow indicates the rupture zone. Movie clip S4. Contrast TTE. Four-chamber view loop. Note contrast filling of the pericardium and opacification of a parallel cavity, in relation to the left ventricle, with systolic and diastolic flow through the rupture. PC = pericardial cavity, LV = left ventricle; LA = left atrium; LW = lateral wall. The arrow indicates the rupture zone. Movie clip S5. Cardiac magnetic resonance (CMR). Cine-sequence (SSFP) at short-axis view. Note the LVWR (arrow) and localized pericardial effusion. PC = pericardial cavity; LV = left ventricle. The arrow indicates the rupture zone. Movie clip S6. CMR. Cine-sequence (SSFP) at short-axis view. Note the LVWR (arrow) and localized pericardial effusion. PC = pericardial cavity; LV = left ventricle. The arrow indicates the rupture zone. Movie clip S7. CMR. Cine-sequence (SSFP) at four-chamber view. Note the LVWR (arrow) and localized pericardial effusion. PC = pericardial cavity; RV = right ventricle; LV = left ventricle; LA = left atrium; RA = right atrium. The arrow indicates the rupture zone. Movie clip S8. CMR. Cine-sequence (SSFP) at five-chamber view. Note the LVWR (arrow) and localized pericardial effusion. PC = pericardial cavity; RV = right ventricle; LV = left ventricle; LA = left atrium; RA = right atrium. The arrow indicates the rupture zone.
Movie clip S9. 3DTTE. 3D full volume cropped image. View from the lateral wall perspective. This loop reveals a pseudoaneurysm and the rupture area at the mid-potion of the left lateral ventricular wall (arrow). LW = lateral wall; LV = left ventricle; LA = left atrium; VPS = ventricular pseudoaneurysm. Movie clip S10. 3DTTE. 3D full volume cropped image. View from the lateral wall perspective. Contrast concentration is greater in LV cavity and there is a clear transit of contrast from cavity to the pseudoaneurysm through the rupture left ventricular wall. LW = lateral wall; LV = left ventricle; LA = left atrium; VPS = ventricular pseudoaneurysm. Movie clip S11. 3DTTE. 3D full volume cropped image in a longitudinal plane. View from the pseudoaneurysm perspective lateral wall perspective pointing out the anatomy of the pseudoaneurysm along the lateral wall from the base to the apex of the heart. LV = left ventricle; LA = left atrium. VPS = ventricular pseudoaneurysm. Movie clip S12. 3DTTE. 3D full volume cropped image in a transversal plane. View from the apex to the base of the LV at the level of lateral wall rupture. Pseudoaneurysm sac shows systolic expansion. LV = left ventricle; VPS = ventricular pseudoaneurysm. Movie clip S13. 3DTTE. 3D full volume processed image with color focusing the lateral wall. Movie clip S14. 3DTTE. 3D full volume postprocessed image with color Doppler. View of the lateral wall from the pseudoaneurysm with color flow Doppler. Note 3 small points that allow the morphological characteristic of the lateral wall rupture.
E299
