Show notes
CardioNerds (Amit and Dan) join Dr. Maria Pabon (cardiology fellow), Dr. Kevin Bersell (cardiology fellow), Dr. Saad Sultan Ghumman (interventional cardiology fellow), and Dr. Rhanderson Cardoso (cardiovascular imaging fellow) from Brigham and Women’s Hospital. Together, they explore a complex case of STEMI that was further complicated by ventricular free wall rupture. Additionally, Dr. Ajar Kochar, Program Director for Interventional Cardiology at Brigham and Women's Hospital, provides an insightful "ECPR" segment, adding a unique perspective to the case. Audio editing by CardioNerds Academy Intern, student doctor Chelsea Amo Tweneboah.
This is the case of a patient who presented with STEMI and was found to have a moderate pericardial effusion with echogenic material within the pericardial space concerning for thrombus. Urgent CTA/CT surgery was engaged due to concern for dissection, but no evidence of dissection, rupture or intramural hematoma was found. The patient underwent an urgent pericardiocentesis which yielded 350cc of hemorrhagic fluid, leading to an improvement in hemodynamic status. A coronary angiogram was performed which showed a 100% thrombotic occlusion of OM 1, the culprit lesion for the STEMI. Due to the possibility of a delayed STEMI and high suspicion for mechanical complication of MI, aspirin and IV cangrelor were chosen as the preferred antiplatelet strategy. However, cangrelor was held and cardiac surgery was consulted, as LV free wall rupture was suspected. The patient underwent urgent repair of the LV free wall rupture, with an uneventful post-op recovery and discharge on day 8 to cardiac rehab.
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Case Media
Pearls - When Infarction Brings the Walls Down - Brigham and Women’s Hospital
In the era of primary PCI, mechanical complications of MI are relatively rare.
Timely recognition using multi-modality imaging and prompt surgical intervention can result in favorable outcomes.
An approach that involves a Heart Team can be advantageous in optimizing outcomes in such complex cases.
Show Notes - When Infarction Brings the Walls Down - Brigham and Women’s Hospital
Incidence of post AMI LV free wall rupture:
0.1-1%
Risk factors for LV Free wall Rupture:
Older age
Female sex
Prior HTN
1st lateral or Anterior Wall MI
Protective factors towards free wall rupture:
LV hypertrophy
CHF
Hx of prior infarcts
Chronic ischemic heart disease
Early use of beta blockers post MI
Timely intervention
Incidence of Mortality associated with mechanical rupture related to AMI:
8-10%
When to suspect a mechanical complication of AMI:
AMI with shock/hypotension
New murmur
New pericardial effusion 10mm on bedside echo
Other etiologies that can cause free wall rupture:
Trauma
Cardiac infection
Aortic dissection
Cardiac tumors
Infiltrative diseases
Iatrogenic from PCI or surgical procedures
References - When Infarction Brings the Walls Down - Brigham and Women’s Hospital
Varghese S, Ohlow MA. Left ventricular free wall rupture in myocardial infarction: A retrospective analysis from a single tertiary center. JRSM Cardiovasc Dis. 2019 Jan-Dec;8:2048004019896692. doi: 10.1177/2048004019896692. PMID: 31970072.
Pineda-De Paz, D.O., Hernández-del Rio, J.E., González-Padilla, C. et al. Left ventricular free-wall rupture, a potentially lethal mechanical complication of acute myocardial infarction: an unusual and illustrative case report. BMC Cardiovasc Disord 19, 80 (2019). https://doi.org/10.1186/s12872-019-1063-x
Yip HK, Wu CJ, Chang HW, Wang CP, Cheng CI, Chua S, Chen MC. Cardiac rupture complicating acute myocardial infarction in the direct percutaneous coronary intervention reperfusion era. Chest 2003;124:565–71. doi: 10.1378/chest.124.2.565. PMID: 12907558.
Sutherland FW, Guell FJ, Pathi VL, Naik SK. Postinfarction ventricular free wall rupture: strategies for diagnosis and treatment. Ann Thorac Surg 1996;61:1281–5. doi: 10.1016/0003-4975(95)00953-6. PMID: 8627055.
Meta-analysis of corticosteroid treatment in acute myocardial infarction. Am J Cardiol 2003;91:1055–9. doi: 10.1016/S0002-9149(03)00216-4. PMID: 12745097.