Asymptomatic incomplete left ventricular apical rupture diagnosed by cardiac magnetic resonance imaging.
Year: 2006
Type: article
Study design: Case Report
Abstract: 66-year-old man presented with a fever of 103 °F, cough, and dyspnea, despite 3 days' treatment of pneumonia. Chest radiography revealed a normal cardiac silhouette and a small left pleural effusion. A baseline electrocardiogram (ECG) showed normal sinus rhythm with profound ST-segment elevation in the anterolateral leads. An ECG obtained 2 months earlier was normal. An echocardiogram showed severe hypokinesis of the anterior, anteroseptal, and apical segments without evidence of a pericardial effusion. Coronary angiography revealed complete occlusion of the proximal left anterior descending coronary artery with severe distal anterior hypokinesis.
Forty-eight hours after admission, the patient had recurrent fever. A repeat transthoracic echocardiogram (Fig. 1) revealed a thin, aneurysmal, left ventricular (LV) apex with pericardium apparently adherent to the apex. In addition, a moderate-to-large, echo-free pericardial effusion was noted. Out of clinical concern for a possible contained LV rupture, cardiac magnetic resonance imaging (CMR) was performed for definitive evaluation and tissue characterization.
Fig. 1 Transthoracic echocardiogram (4-chamber view at end-systole) reveals an apex-sparing pericardial effusion and an aneurysmal left ventricular apex.
The CMR (Figs. 2 and 3) revealed evidence of a large myocardial infarction (MI) with subsequent aneurysm formation involving the distal half of the left anterior descending artery distribution and the entire apex, with an extensive amount of thrombus in the apex. A “hinge-point” involving the lateral and anterolateral walls was noted, raising the concern of a possible contained rupture of the LV apex. A large, predominantly simple-appearing pericardial effusion was noted circumferentially, but the apex was spared. The pericardium was hyperenhanced on viability/ scar imaging in the regions of infarct, suggesting post-MI pericarditis.
Fig. 2 Cine cardiac magnetic resonance imaging demonstrates a large aneurysmal area involving the distal half of the left anterior descending coronary artery distribution with an extensive amount of thrombus at the apex. A hinge-point involving the lateral ...
Fig. 3 Viability/scar imaging reveals a transmural infarction of the affected area. The remainder of the left ventricular myocardium appears to be of full thickness and viable. There is also hyperenhancement of the pericardium in the infarct regions, ...
A follow-up echocardiogram performed 1 week later showed a slight decrease in the size of the pericardial effusion. Repair of the LV was deferred until effective surgical suturing could be performed on the infarcted area.
Eight weeks later, the patient underwent successful LV endoaneurysmorrhaphy with a Dacron patch. Intraoperatively, a 3- × 4-cm balloon-like aneurysm was found to be fused to the pericardial sac. The aneurysm was excised, and subsequent microscopic evaluation revealed necrotic myocardium and reactive connective tissue (Fig. 4). The patient had an uneventful hospital course and was discharged from the hospital in stable condition. At a follow-up visit 2 months later, he reported a substantial increase in exercise tolerance and a return to usual daily activities.
Fig. 4 Photomicrograph illustrates necrotic myocardium and adjacent reactive connective tissue. (H & E, orig. ×100)
Source: Europe PMC (PubMed Central)
Language: English
Subfield: Surgery
Field: Medicine
Domain: Health Sciences
Open Access status: green
OpenAlex ID: W2291845419