The dark side of myocardial infarction

Introducere: Complications of myocardial infarction are arrhythmic, inflammatory, and mechanical com-plications. Other possible complications are right ventricular infarction and cardiogenic shock. The 3 major mechanical complications are ventricular free wall rup-ture, ventricular septal rutpure and papillary muscule rupture. Rupture of the free wall of the left ventricle is the most catastrophic mechanical complication of acute MI with a moratlity rater in excess of 90%. The presentation is one of pericardial tamponade and he-modynamic collaps, often culminating in pulseless electrical activity. The most common location of rupture is in the anterior and lateral distributions of the left anterior descending artery. Survival is dependent on prompt recognition, emergent pericadiocentesis, and surgical repair.

Case presentation: A 46- year old patient, smoker wi-thout a history of heredocolateral and personal patho-logy, presents in the emergency department for ante-rior chest pain with onset of 9 hours, accompanied by profuse sweating. Physical examination revealed cold sweaty skin, overweight, regular heart sounds, without overwhelmed murmurs, HR= 75bpm, ABP= 110/70. The biological findings showed hyperglicemia, minor hepatocytolisis and leukocytosis with neutrophilia. ECG presented SR, HR= 65bpm, Q in the lower seg-ment, elevation of ST segment about 2 mm and nega-tive T in the inferolateral territory. At the same time, an increase in the dynamics of troponins was observed (14.1 ng/ml to 27.5 ng/ml). TTE revealed left ventri-cle with hypokinesia of the inferolateral wall. Corona-rography was performed where thrombotic occlusion was observed at the level of the second half of the ri-ght coronary artery, resulting primary angioplasty with two stents on the right coronary artery. Patient was managed as inferolateral STEMI with aspirin, clopido-grel, atorvastatin, perindopril and bisoprolol. The next day, during the morning, the patient presents an altered general condition, cardiogenic shock, self-limited ven-tricular tachycardia without angina and dyspnea. TTE showed left ventricle without enlargement, EF: 40-45%, with doppler signal present at the apical portion of the free wall of the left ventricle, interpreted as myocardial rupture. CT scan with contrast was performed which confirmed the diagnosis of free wall rupture of the left ventricle. Coronarography was normal, without chan-ges. The patient was treated and stabilized with amio-darone, lidocaine, magnesium sulfate, dobutamine and underwent surgery with repair of the damaged area of the left ventricle.

Particularity: 46 years old patient, smoker, without a history of heredocolateral and personal pathology, has the diagnosis of myocardial infarction followed by complications such as cardiogenic shock, ventricular  tachycardia and myocardial rupture. Rupture of the free wall of the left ventricle is found in less than 1% of living patients with an acute myocardial infarction. Early diagnosis of myocardial rupture is crucial if life saving therapy is to be applied. Recent chest pain with further ST-segement elevation, hypotension, and cardi-ogenic shock in the setting of an acute or recent myo-cardial infarction should alert clinicians to the possibi-lity of this complications, particulary in patients with an extensive transmural (Q-wave) infarction.

ISSN – online: 2734 – 6382
ISSN-L 1220-658X
ISSN – print: 1220-658X
The Romanian Journal of Cardiology is indexed by:
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CODE: 379
CME Credits: 10 (Romanian College of Physicians)