Dipesh Ludhwani
Rosalind Franklin University, USA
Title: Left Ventricular free wall rupture: A rare complication of acute myocardial Infarction
Biography
Biography: Dipesh Ludhwani
Abstract
Introduction: Coronary artery disease (CAD) remains the leading cause of mortality worldwide. 40% of patients with CAD present as Acute Myocardial Infarction (AMI). More than half of AMI related deaths occur before reaching the hospital. Arrhythmia remains the most common cause of death in such patients. Left ventricular free wall rupture (LVFWR) is a rare complication of AMI occurring in approximately 2% of cases postcatheterization. Most acute cases present with symptoms of angina and sudden hemodynamic collapse. In one-third cases, organized thrombus and pericardium can seal the perforation causing subacute rupture.
Case Presentation: An 83-year-old male with a past medical history of coronary artery disease status post four vessel bypass graft ten years ago presented to ED with complaints of chest pain and shortness of breath from last one week. On presentation, the patient had normal vitals and lateral lead ST-T changes on electrocardiogram. Labs revealed troponin of 10.20ng/ml and elevated S. creatinine (1.55mg/dl). An overhead cardiac alert was called and the patient was transferred to the Cath lab for presumed AMI. Coronary angiogram showed patent bypass grafts and left ventricular anterior wall aneurysm. Post-angiogram patient had a transthoracic echocardiogram (TTE) which revealed left ventricle anterior free wall rupture which was later confirmed on CT angiogram of the chest. Cardiothoracic surgery was consulted however surgery was delayed to allow stabilization of friable necrotic tissue and to let clopidogrel wear off. During this period patient had regular follow-up TTE to monitor LVFWR. Rupture size was kept in check with a strict heart rate and blood pressure control. The patient finally underwent redo-sternotomy with patch closure of left ventricular rupture site. Postoperatively patient was hemodynamically supported with Intra-aortic balloon pump (IABP) temporarily. Further course remained uncomplicated and the patient was discharged to an acute care facility for supervised cardiac rehabilitation.
Discussion: LVFWR is a deadly complication of AMI occurring between 5-14 days after AMI. LWFWR should be suspected in patients with persistent chest pain especially after a recent coronary event. A normal angiogram with non-obstructive coronary arteries after recent AMI should not exclude this diagnosis as LVFWR has been reported in patients with Myocardial Infarction with Normal Coronary Arteries (MINCA). Management is dictated by the acuity of presentation. Medical therapy to hemodynamically stabilize the patient followed by emergent surgery remains the mainstay treatment option. Biocompatible glues and patches are increasingly preferred over infarctectomy and direct myocardial suturing to cover rupture site. Despite high peri-operative mortality rate rapid institution of treatment is associated with improved long-term survival.