Case Report
Ventricular Septal Rupture, Right Ventricular Dissection, and Tricuspid Chordae Rupture— A Rare Complication After Inferior and Right Ventricular Infarction Xiao-hong Li, MD,1 Ying Zhao, MD,2 Jianzeng Dong, MD,1 Yihua He, MD,2 Wenxu Liu, MD,2 Jiancheng Han, MD2 1 2
Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, Beijing, China Ultrasound Department, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
Received 10 January 2014; accepted 14 August 2014
ABSTRACT: A 76-year-old man under stable hemodynamic condition was admitted to our hospital for delayed percutaneous coronary intervention following a diagnosis of acute inferior myocardial infarction. Bedside echocardiography revealed ventricular septal rupture at the basal posteroinferior wall with a large left-to-right shunt. Right ventricular free-wall intramyocardial dissection and tricuspid chordae rupture were noted. Coronary angiography demonstrated occlusion of the proximal right coronary artery, which was treated by balloon angioplasty and stenting. While preparing for surgical repair, the patient’s overall cardiac and renal function deteriorated and surgery was contraindicated. The patient died 16 days C 2014 Wiley Periodicals, Inc. J Clin after discharge. V Ultrasound 43:512–515, 2015; Published online in Wiley Online Library (wileyonlinelibrary.com). DOI: 10.1002/jcu.22235 Keywords: right ventricular wall dissection; ventricular septal rupture; tricuspid chordae rupture; acute inferior myocardial infarction
T
he occurrence of ventricular septal rupture (VSR) after acute myocardial infarction is
We would like to confirm that all authors contributed to the manuscript and believe that it is original; none of the authors has a conflict of interest to disclose. The paper is not currently under consideration elsewhere, and none of the paper’s contents have been previously published. Additional Supporting Information may be found in the online version of this article. Correspondence to: J. Dong C 2014 Wiley Periodicals, Inc. V
512
an uncommon complication in the reperfusion era. Its mortality rate is extremely high despite the performance of surgical repair.1 Early recognition of this complication using transthoracic echocardiography is helpful to improve the patient’s prognosis.2 CASE REPORT
A 76-year-old man was admitted to our hospital for further treatment following a diagnosis of acute inferior myocardial infarction at a local hospital. He had a 15-day history of typical chest pain and palpitation. On admission, his blood pressure was 105/70 mmHg and heart rate was 102 bpm. Electrocardiography showed “frozen” ST elevation and Q waves in leads II, III, and aVF. Bedside echocardiography revealed a 41 3 30-mm left ventricular posteroinferior wall aneurysm and a 13-mm VSR at the basal posteroinferior wall (Figure 1A; Video 1) with a large left-toright shunt on color Doppler (maximum velocity, 366 cm/s; pressure gradient, 53 mmHg) (Figure 1B; Video 2). His left ventricular ejection fraction was 50%. Right ventricular (RV) wall motion hypokinesia was also present with clear evidence of intramyocardial dissection as seen from the subcostal view (Figure 1C; Video 3), mild pericardial effusion, and tricuspid chordae rupture as seen from the apical four-chamber view (Figure 1D; Videos 4 and 5).The papillary muscle could be seen at the head of the ruptured chordate. Massive systolic tricuspid regurgitation was also JOURNAL OF CLINICAL ULTRASOUND
RIGHT VENTRICULAR DISSECTION
FIGURE 1. Transthoracic echocardiography shows (A) inferior ventricular septal rupture (arrowhead) and (B) left-to-right shunt (arrowhead). Subcostal view shows (C) right ventricular dissection (asterisk) and (D) tricuspid valve rupture (arrowhead). RV, right ventricle; LV, left ventricle; PE pericardial effusion; AO, aorta; RA, right atrium; LA, left atrium.
observed. Coronary angiography demonstrated occlusion of the proximal right coronary artery, which was treated by balloon angioplasty and stenting, based on joint cardiac and surgical consensus opinion (Figure 2). While preparing for surgical repair of the VSR and tricuspid valve, the patient’s overall cardiac and renal function deteriorated and surgery was contraindicated. The patient was discharged 6 days later, but died 16 days after discharge.
DISCUSSION
We report a single case of multiple severe complications of myocardial infarction. Echocardiography revealed resultant structural defects. VSR with RV free-wall intramyocardial dissection is a very rare complication after inferior and RV myocardial infarction. It was first described in autopsy studies in 19773 and by echocardiography in 1986.4 To the best of our knowledge, this is the first reported case of simultaneous VSR, RV myocardial dissection, VOL. 43, NO. 8, OCTOBER 2015
and tricuspid chordae rupture. The cause of these complications was a lesion in the proximal right coronary artery. Transthoracic echocardiography, especially the subcostal view, demonstrated the position, area, and blood flow in and out of the RV intramyocardial dissection. The RV papillary muscle ischemia and tricuspid chordae rupture occurred secondary to complete occlusion of the right coronary artery. The right coronary angioplasty was performed for RV myocardial revascularization and function improvement. Considering the large size of the VSR, shunt, and RV dissection and the severity of the tricuspid regurgitation, surgical repair seemed mandatory.2,5 However, progressive deterioration of both cardiac and renal function did not allow for surgery. This case is an example of how RV wall dissection may occur under stable hemodynamic conditions. This rare mechanical complication can be detected on routine echocardiography. Prompt recognition by echocardiography is important because such patients may remain clinically asymptomatic until the development of 513
LI ET AL
FIGURE 2. Coronary angiography shows (A) occlusion of the proximal part of the right coronary artery (arrow), (B) Guildwire was advanced to the distal of right coronary artery, (C) The lesion was dilated by the baloon, and (D) stent implantation to completely reopen the right coronary artery.
cardiogenic shock. The use of subcostal views to visualize the RV free wall allows for the detection of the left ventricular entry site and the RV exit site of the septal rupture. Differential diagnosis of RV dissection includes pseudo-aneurysm (which can be ruled out by echocardiographic evidence of myocardial separation, absence of a narrow neck, and absence of epicardial rupture) and true aneurysm (which can be ruled out by echocardiographic evidence of a complete and continuous endocardium, absence of bulging, and absence of expansion). Outcomes after RV intramyocardial dissection following septal rupture related to myocardial infarction are reportedly dismal. The patient described herein missed the time window for emergency percutaneous coronary intervention 514
(PCI); he was transferred to our hospital for delayed PCI after 15 days in the previous hospital. Delayed stent implantation did not save his life. Hochman et al6,7 studied patients with cardiogenic shock undergoing early revascularization by PCI or coronary artery bypass graft surgery. They showed that such patients had substantially better initial and long-term survival rates than patients undergoing initial intensive medical therapy followed by no or late in-hospital revascularization. This may explain why late angioplasty was not helpful in the present case, especially in the setting of multiple mechanical complications. Soriano et al8 reported a case similar to ours in which the time window of emergency PCI was missed. However, their patient survived. JOURNAL OF CLINICAL ULTRASOUND
RIGHT VENTRICULAR DISSECTION
The authors stated that early recognition of this complication using bedside transthoracic echocardiography and prompt surgical repair are the main factors associated with the achievement of long-term survival in such patients. However, the progressive deterioration of both cardiac and renal function did not allow for surgical repair in our patient, who died. This case alerts to the potential for severe mechanical complications in patients with inferior myocardial infarction, even those under stable hemodynamic conditions. Early recognition of this complication may save the lives of patients.
3.
4.
5.
6. REFERENCES 1. Crenshaw BS, Granger CB, Birnbaum Y, et al. Risk factors, angiographic patterns, and outcomes in patients with ventricular septal defect complicating acute myocardial infarction. GUSTO-1 (Global Utilization of Streptokinase and TPA for Occluded Coronary Arteries) Trial Investigators. Circulation 2000;101:27. 2. Tighe DA, Paul JJ, Maniet AR, et al. Survival in infarct related intramyocardial dissection impor-
VOL. 43, NO. 8, OCTOBER 2015
7.
8.
tance of early echocardiography and prompt surgery. Echocardiography 1997;14:403. Daubert JC, Mattheyses M, Fourdilis M, et al. Infarction of the right ventricle. 2. Prognostic and therapeutic aspects. Arch Mal Coeur Vaiss 1977; 70:257. Scanu P, Lamy E, Commeau P, et al. Myocardial dissection in right ventricular infarction: two-dimensional echocardiographic recognition and pathologic study. Am Heart J 1986;111: 422. Chan W, Yan B, Warren R, et al. A rare complication of left ventricular rupture–right ventricular intramyocardial dissection with left-to-right shunting. Int J Cardiol 2007;121:e19. Hochman JS, Sleeper LA, Webb JG, et al. Early revascularization improves long-term survival for cardiogenic shock complicating acute myocardial infarction. JAMA 2006;295:2511. Hochman JS, Sleeper LA, White HD, et al. Oneyear survival following early revascularization for cardiogenic shock. J Am Med Assoc 2001;285: 190. Soriano CJ, Perez-Bosc a JL, Canovas S, et al. Septal rupture with right ventricular wall dissection after myocardial infarction. Cardiovasc Ultrasound 2005;3:33.
515
Ventricular Septal Rupture, Right Ventricular Dissection, and Tricuspid Chordae Rupture— A Rare Complication After Inferior and Right Ventricular Infarction Xiao-hong Li, MD,1 Ying Zhao, MD,2 Jianzeng Dong, MD,1 Yihua He, MD,2 Wenxu Liu, MD,2 Jiancheng Han, MD2 1 2
Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, Beijing, China Ultrasound Department, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
Received 10 January 2014; accepted 14 August 2014
ABSTRACT: A 76-year-old man under stable hemodynamic condition was admitted to our hospital for delayed percutaneous coronary intervention following a diagnosis of acute inferior myocardial infarction. Bedside echocardiography revealed ventricular septal rupture at the basal posteroinferior wall with a large left-to-right shunt. Right ventricular free-wall intramyocardial dissection and tricuspid chordae rupture were noted. Coronary angiography demonstrated occlusion of the proximal right coronary artery, which was treated by balloon angioplasty and stenting. While preparing for surgical repair, the patient’s overall cardiac and renal function deteriorated and surgery was contraindicated. The patient died 16 days C 2014 Wiley Periodicals, Inc. J Clin after discharge. V Ultrasound 43:512–515, 2015; Published online in Wiley Online Library (wileyonlinelibrary.com). DOI: 10.1002/jcu.22235 Keywords: right ventricular wall dissection; ventricular septal rupture; tricuspid chordae rupture; acute inferior myocardial infarction
T
he occurrence of ventricular septal rupture (VSR) after acute myocardial infarction is
We would like to confirm that all authors contributed to the manuscript and believe that it is original; none of the authors has a conflict of interest to disclose. The paper is not currently under consideration elsewhere, and none of the paper’s contents have been previously published. Additional Supporting Information may be found in the online version of this article. Correspondence to: J. Dong C 2014 Wiley Periodicals, Inc. V
512
an uncommon complication in the reperfusion era. Its mortality rate is extremely high despite the performance of surgical repair.1 Early recognition of this complication using transthoracic echocardiography is helpful to improve the patient’s prognosis.2 CASE REPORT
A 76-year-old man was admitted to our hospital for further treatment following a diagnosis of acute inferior myocardial infarction at a local hospital. He had a 15-day history of typical chest pain and palpitation. On admission, his blood pressure was 105/70 mmHg and heart rate was 102 bpm. Electrocardiography showed “frozen” ST elevation and Q waves in leads II, III, and aVF. Bedside echocardiography revealed a 41 3 30-mm left ventricular posteroinferior wall aneurysm and a 13-mm VSR at the basal posteroinferior wall (Figure 1A; Video 1) with a large left-toright shunt on color Doppler (maximum velocity, 366 cm/s; pressure gradient, 53 mmHg) (Figure 1B; Video 2). His left ventricular ejection fraction was 50%. Right ventricular (RV) wall motion hypokinesia was also present with clear evidence of intramyocardial dissection as seen from the subcostal view (Figure 1C; Video 3), mild pericardial effusion, and tricuspid chordae rupture as seen from the apical four-chamber view (Figure 1D; Videos 4 and 5).The papillary muscle could be seen at the head of the ruptured chordate. Massive systolic tricuspid regurgitation was also JOURNAL OF CLINICAL ULTRASOUND
RIGHT VENTRICULAR DISSECTION
FIGURE 1. Transthoracic echocardiography shows (A) inferior ventricular septal rupture (arrowhead) and (B) left-to-right shunt (arrowhead). Subcostal view shows (C) right ventricular dissection (asterisk) and (D) tricuspid valve rupture (arrowhead). RV, right ventricle; LV, left ventricle; PE pericardial effusion; AO, aorta; RA, right atrium; LA, left atrium.
observed. Coronary angiography demonstrated occlusion of the proximal right coronary artery, which was treated by balloon angioplasty and stenting, based on joint cardiac and surgical consensus opinion (Figure 2). While preparing for surgical repair of the VSR and tricuspid valve, the patient’s overall cardiac and renal function deteriorated and surgery was contraindicated. The patient was discharged 6 days later, but died 16 days after discharge.
DISCUSSION
We report a single case of multiple severe complications of myocardial infarction. Echocardiography revealed resultant structural defects. VSR with RV free-wall intramyocardial dissection is a very rare complication after inferior and RV myocardial infarction. It was first described in autopsy studies in 19773 and by echocardiography in 1986.4 To the best of our knowledge, this is the first reported case of simultaneous VSR, RV myocardial dissection, VOL. 43, NO. 8, OCTOBER 2015
and tricuspid chordae rupture. The cause of these complications was a lesion in the proximal right coronary artery. Transthoracic echocardiography, especially the subcostal view, demonstrated the position, area, and blood flow in and out of the RV intramyocardial dissection. The RV papillary muscle ischemia and tricuspid chordae rupture occurred secondary to complete occlusion of the right coronary artery. The right coronary angioplasty was performed for RV myocardial revascularization and function improvement. Considering the large size of the VSR, shunt, and RV dissection and the severity of the tricuspid regurgitation, surgical repair seemed mandatory.2,5 However, progressive deterioration of both cardiac and renal function did not allow for surgery. This case is an example of how RV wall dissection may occur under stable hemodynamic conditions. This rare mechanical complication can be detected on routine echocardiography. Prompt recognition by echocardiography is important because such patients may remain clinically asymptomatic until the development of 513
LI ET AL
FIGURE 2. Coronary angiography shows (A) occlusion of the proximal part of the right coronary artery (arrow), (B) Guildwire was advanced to the distal of right coronary artery, (C) The lesion was dilated by the baloon, and (D) stent implantation to completely reopen the right coronary artery.
cardiogenic shock. The use of subcostal views to visualize the RV free wall allows for the detection of the left ventricular entry site and the RV exit site of the septal rupture. Differential diagnosis of RV dissection includes pseudo-aneurysm (which can be ruled out by echocardiographic evidence of myocardial separation, absence of a narrow neck, and absence of epicardial rupture) and true aneurysm (which can be ruled out by echocardiographic evidence of a complete and continuous endocardium, absence of bulging, and absence of expansion). Outcomes after RV intramyocardial dissection following septal rupture related to myocardial infarction are reportedly dismal. The patient described herein missed the time window for emergency percutaneous coronary intervention 514
(PCI); he was transferred to our hospital for delayed PCI after 15 days in the previous hospital. Delayed stent implantation did not save his life. Hochman et al6,7 studied patients with cardiogenic shock undergoing early revascularization by PCI or coronary artery bypass graft surgery. They showed that such patients had substantially better initial and long-term survival rates than patients undergoing initial intensive medical therapy followed by no or late in-hospital revascularization. This may explain why late angioplasty was not helpful in the present case, especially in the setting of multiple mechanical complications. Soriano et al8 reported a case similar to ours in which the time window of emergency PCI was missed. However, their patient survived. JOURNAL OF CLINICAL ULTRASOUND
RIGHT VENTRICULAR DISSECTION
The authors stated that early recognition of this complication using bedside transthoracic echocardiography and prompt surgical repair are the main factors associated with the achievement of long-term survival in such patients. However, the progressive deterioration of both cardiac and renal function did not allow for surgical repair in our patient, who died. This case alerts to the potential for severe mechanical complications in patients with inferior myocardial infarction, even those under stable hemodynamic conditions. Early recognition of this complication may save the lives of patients.
3.
4.
5.
6. REFERENCES 1. Crenshaw BS, Granger CB, Birnbaum Y, et al. Risk factors, angiographic patterns, and outcomes in patients with ventricular septal defect complicating acute myocardial infarction. GUSTO-1 (Global Utilization of Streptokinase and TPA for Occluded Coronary Arteries) Trial Investigators. Circulation 2000;101:27. 2. Tighe DA, Paul JJ, Maniet AR, et al. Survival in infarct related intramyocardial dissection impor-
VOL. 43, NO. 8, OCTOBER 2015
7.
8.
tance of early echocardiography and prompt surgery. Echocardiography 1997;14:403. Daubert JC, Mattheyses M, Fourdilis M, et al. Infarction of the right ventricle. 2. Prognostic and therapeutic aspects. Arch Mal Coeur Vaiss 1977; 70:257. Scanu P, Lamy E, Commeau P, et al. Myocardial dissection in right ventricular infarction: two-dimensional echocardiographic recognition and pathologic study. Am Heart J 1986;111: 422. Chan W, Yan B, Warren R, et al. A rare complication of left ventricular rupture–right ventricular intramyocardial dissection with left-to-right shunting. Int J Cardiol 2007;121:e19. Hochman JS, Sleeper LA, Webb JG, et al. Early revascularization improves long-term survival for cardiogenic shock complicating acute myocardial infarction. JAMA 2006;295:2511. Hochman JS, Sleeper LA, White HD, et al. Oneyear survival following early revascularization for cardiogenic shock. J Am Med Assoc 2001;285: 190. Soriano CJ, Perez-Bosc a JL, Canovas S, et al. Septal rupture with right ventricular wall dissection after myocardial infarction. Cardiovasc Ultrasound 2005;3:33.
515
