When nature can do better than medicine

Introduction: Left ventricle free wall rupture is not rare because it represents 0.8-6.2% of all cases of ST seg-ment elevation myocardial infarction and often evolves with severe complications. Left ventricular (LV) pseu-doaneurysm is a contained cardiac rupture which is en-circled by adherent pericardium or scar tissue, with no myocardial tissue. Left ventricular aneurysm (differen-tial diagnosis required) has a wall of myocardium and a scarring endocardium. Diagnosis and therapy of this type of complication is a challenge. Diagnosis is usually suggested by haemodynamic collapse and confirmed by repeated transthoracic echocardiography.

Methods: We present a case of acute myocardial infarc-tion complicated by left ventricular pseudoaneurysm resulting from the closed myocardial rupture in the 70-year-old patient known for stage III chronic renal disease with no significant cardiovascular history. The onset of angina symptoms is several hours prior to ho-spital admission. He is diagnosed with inferior-lateral STEMI, raising suspicion of myocardial wall rupture with hemopericardium.

Results: T horacic CT is performed showing a spon-taneous hyperdense accumulation in the pericardial sac, measuring 18 mm adjacent to the right ventricle, 15 mm apical LV and 17 mm adjacent to the left ven-tricle. The patient is admitted in the ICU to monitor and support vital functions. An emergency diagnos-tic coronary angiography was performed, the patient being scheduled for emergency cardiac surgery. The coronarography revealed occlusion of the middle seg-ment of left circumflex artery, with non-critical steno-ses on other vessels. Ventriculography emphasizes the presence of extra LV contrast with suggestive image of myocardial rupture without extension during imaging evaluation. Initial ultrasound reveals a preserved LV function, the presence of circumferential pericardial fluid with fibrin adhering to the LV wall and pericar-dial space of thickness >20 mm. Immediate progres-sion is stricken by signs of shock with hemodynamic collapse. It requires inotropic vasopressor support, orotracheal intubation and mechanical ventilation. The patient evolves with LVEF depression at 30% without the extension of the pericardial fluid accumulation. It is decided to delay the surgery until the patient’s he-modynamic stabilization. Evolution is slowly favorable, with discharge on day 29. An important challenge was the choice of antiplatelet treatment in the patient with indication of maximal treatment for acute myocardial infarction treated conservatively and contraindication of antithrombotic treatment for pericardial effusion. We initially decided monoantiplatelet therapy with ti-cagrelor associated with heparinotherapy in a prophy-lactic dose for pulmonary embolism. With the patient’s mobilization on day 18, we decided to continue strictly the therapy with P2Y12 receptor blocker.

Conclusions: In the case of pseudoaneurysm, the car-diac rupture is closed by adherent pericardium or scar tissue. Myocardial rupture is usually rapidly fatal, how-ever, in this scenario, it is fortuitously limited by a pe-ricardial adherence. Surgery usually is recommended in cases with symptomatic status, giant aneurysm size, and an impending rupture. Conservative therapy can be considered in asymptomatic cases, those with small aneurysms (<3 cm) and those with a stable dimension during regular follow-up.

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)