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TRANSCRIPT
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