European Journal of Echocardiography 2008 9(1):92-94; doi:10.1016/j.euje.2007.02.009
Published on behalf of the European Society of Cardiology. All rights reserved. © The Author 2007. For permissions please email: journals.permissions@oxfordjournals.org.
Unexpected rupture of the left ventricular free wall in the echo-lab
Magnus Dencker1,*,
Gordana Tasevska2,
David Grubb3,
Martin Stagmo2 and
Ronny Gustafsson3
1 Department of Clinical Sciences, Unit of Clinical Physiology and Nuclear Medicine, University Hospital MAS, 205 02 Malmö, Sweden
2 Department of Cardiology, University Hospital MAS, Malmö, Sweden
3 Heart and Lung Division, University Hospital Lund, Lund, Sweden
Received 26 January 2007; accepted after revision 14 February 2007; online publish-ahead-of-print 5 April 2007.
* Corresponding author. Tel: +46 40 338 731; fax: +46 40 338 768. E-mail address: magnus.dencker{at}skane.se
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Abstract
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Background: Left ventricular free wall rupture is an uncommon but catastrophic
event following myocardial infarction, and considered the second
leading cause of death in acute myocardial infarct. Different
types of rupture exist from acute to sub acute types, but prognosis
is usually poor. Early recognition and aggressive treatment
is recommended.
Case report: We present a case of a 75-year-old man who was referred to our echo-lab for an out patient evaluation because of 1-week duration of worsening of chest pain. Standard transthoracic echocardiography showed hypokinesia in the apical portion of the anterior wall and basal portion of the inferior wall. The patient complained of shortness of breath immediately after the conclusion of the exam, and soon afterward became unconscious. Renewed echocardiography approximately 1 min after syncope displayed a newly developed echo-lucent rim around the heart consistent with left ventricular free wall rupture. Resuscitation was performed followed by attempts to evacuate the blood by needle aspiration, which failed. Open pericardiocentesis stabilised the patient until surgery could be performed. The patient survived and could be discharged 2 weeks later.
Conclusion: This case highlights the fact that rapid and accurate diagnosis is essential if patients with left ventricular free wall rupture are to survive.
Keywords: Left ventricular free wall rupture; Echocardiography; Surgery; Myocardial infarction
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Introduction
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Left ventricular free wall rupture is an uncommon but catastrophic
event following myocardial infarction and is associated with
a high mortality. The rupture and subsequent development of
pericardial tamponade results in sudden and critical change
in hemodynamics. A fast and sensitive diagnostic test to confirm
cardiac rupture is transthoracic echocardiography. We present
a case of unexpected rupture of the left ventricular free wall
in a patient referred to the echo-lab for an outpatient evaluation.
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Case report
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A 75-year-old male with two previous myocardial infarctions
was referred for echocardiography by the patients treating cardiologist
because of worsening of angina. He was an out-patient referral,
not admitted in the Hospital (he had refused admission). The
patient underwent standard transthoracic echocardiography that
showed moderate hypokinesia in the basal portion of the inferior
wall and a small segment of hypokinesia in the apical part of
the anterior wall. The patient complained of shortness of breath
immediately after the conclusion of the echocardiography exam,
and soon afterward became unconscious. ECG displayed normal
regular sinus rhythm whereas echocardiography approximately
1 min after syncope showed a newly developed echo-lucent rim
around the heart consistent with the diagnosis of left ventricular
free wall rupture.
Figures 1 and
2 are end-diastolic images
from apical 4-chamber view prior to syncope and after syncope.
Figures 3 and
4 are corresponding images from apical 2-chamber
view. Cardiopulmonary resuscitation was started immediately.
Several attempts were made to evacuate the blood in the pericardium
by needle aspiration, but these attempts failed presumably due
to poor diameter of the needle in combination with clotting
of the blood. Decision was made to drain the pericardium by
open pericardiocentesis, which was performed with an approximately
2 cm long sub-Xiphoid incision followed by blunt dissection
through the diaphragm.
The results both from a hemodynamic and echocardiography point
of view were dramatic. Left ventricular ejection fraction improved
from basically zero to approximately 40% and significant reduction
of the echo-lucent rim around the heart was observed. After
stabilisation, the patient was transferred to a tertiary hospital
for cardiac surgery. Median sternotomy was performed and patient
was put on cardiopulmonary bypass. He was cooled to 33°C.
A frank tamponade was found and the clots were carefully removed.
A Dacron patch was tailored to cover the posterolateral infarct
area of the heart and covered with bioglue. The heart was lifted
and the patch was put on the infarct area with gentle compression.
The weaning from the heart and lung machine was uneventful.
Postoperative echocardiography showed complete regression of
the pericardial effusion. The patient survived and could be
discharged 2 weeks later.
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Discussion
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Rupture of the heart during the course of a myocardial infarct
may occur at different locations such as the left ventricular
free wall, ventricular septum, papillary muscle and the atria.
1 The most common type is left ventricular free wall rupture,
as in our case, and this condition is considered second leading
cause of death in patients with myocardial infarct.
1 The incidence
varies in previous reports, but a large review from the pre-fibrinolytic
and PCI eras suggest an average incidence of 8% of all fatal
myocardial infarcts.
2 The overall incidence of left ventricular
free wall rupture in all acute myocardial infarcts is low, for
example The international SHOCK Trial Registry found a prevalence
of free-wall rupture or tamponade of 2.7%,
3 and the US national
registry data suggested even lower percentage (<1%).
4 Recent
reports from single centres are in the range of 1–2.5%,
5,6 and it has been suggested that primary PCI may decrease the
incidence.
5,6
There are a number of risk indicators that are associated with cardiac rupture, such as female gender, old age (>65 years), hypertension, and first myocardial infarct.1 Typical signs and symptoms of myocardial rupture are recurrent or persistent chest pain, syncope, distension of jugular veins and also electrocardiographic signs such as sinus tachycardia, persistent ST elevation, and new Q-waves.1
Fast and accurate diagnosis is essential if patients with left ventricular free wall rupture are to survive. Two-dimensional echocardiography as used in the present case report is often considered the method of choice. A variety of other methods for non-invasive diagnosis of rupture of a free left ventricular wall have been reported. For example, the use of intravenous injections of a contrast agent during two-dimensional echocardiography have visualised myocardial rupture secondary to acute myocardial infarction.7,8 Also, live three-dimensional echocardiography has been shown to accurately diagnose the rupture site.9 In addition, diagnosis of left ventricular free-wall rupture by magnetic resonance or CT scan have also been reported.10,11
Emergency surgery is the treatment method of choice, since conservative treatment has been shown to have very poor prognosis.2 Several different types of surgical techniques have been used in the past such as closing the rupture with prosthetic patch combined with sutures or performing a resection of infarcted myocardium, both performed with use of extracorporeal circulation,12 whereas a new technique utilising a patch combined with tissue glue has emerged in recent years.13,14
Did the standard two-dimensional echocardiography examination facilitate the rupture? There has been report of left ventricular free wall rupture during stress echocardiography,15 but in such a situation one would expect that this was caused by the dobutamine stress and presumably not by the energy emitted as part of the echocardiography examination. A recent experimental study by Olivecrona and co-workers has investigated this hypothesis.16 The effect of exposing infarcted myocardium to ultrasound was evaluated in a porcine model. Histopathological evaluation of tissue damage revealed a significant increase in tissue damage in those animals that had been exposed to prolonged ultrasound. However, the exposure time was 1 h in the experiment whereas the average echocardiography examination probably only takes 30 min. The frequency used in the experiment was 1 MHz, which is slightly lower than the frequency used in cardiac diagnostic ultrasound. On the other hand the intensity was set at 0.1 W/cm2 whereas echocardiographic ultrasound may have a spatial average temporal intensity of 1.9 W/cm2. Needless to say pigs are pigs, not humans.
In conclusion, this case report highlights the importance of rapid and accurate diagnosis by echocardiography in patients with left ventricular free wall rupture if such a patient is to survive.
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References
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Abstract
Introduction
