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Cardiac Amyloidosis Causing Free Wall Rupture During an Exercise Stress Test: A Case Report and Review of the Literature

Year: 2023

Type: article

Abstract: Background: There are three major mechanical complications from acute myocardial infarction: left ventricular free-wall rupture, ventricular septum rupture and acute mitral valve regurgitation.The left ventricular free-wall rupture is a serious and often lethal complication, typically following an ST elevation myocardial infarction.Free wall rupture outside the setting of a recent ST elevation myocardial infarction is very unusual.Furthermore, rupture during stress testing is extremely uncommon with very few cases in the literature.In addition to causing restrictive cardiomyopathies, cardiac amyloidosis can also cause severe ischemia with potentially catastrophic complications including free wall rupture. Case Presentation:We present a 75-year-old white male with dyslipidemia who presented to his internist with intermittent chest pressure for several days which was initially exertional.The night prior to seeing his internist, the discomfort was present while lying in bed.His EKG was unchanged from prior with no acute ischemic changes and an old RBBB.A stress echo was ordered which was obtained six days later.His baseline echocardiogram revealed normal wall thickness, an ejection fraction of 60% with very mild hypokinesia of the lateral wall.He exercised for a total of 7 minutes and 30 seconds and stopped exercise due to light headedness.He developed 4 mm of ST depression in the right precordial leads in early recovery.He subsequently went into PEA arrest and was noted to have a new pericardial effusion with tamponade physiology.Despite ACLS protocol and attempt at pericardiocentesis, he died in the stress lab before he could be taken for emergent surgery.Autopsy conveyed acute and subacute infarction of the posterior and lateral wall with left ventricular rupture.The degree of coronary disease was only moderate.Further evaluation of the myocardium conveyed diffuse transthyretin amyloidosis (ATTR).Conclusion: Underlying cardiac amyloidosis can directly cause ischemia and infarction due to microvascular disease.If severe ischemia develops before significant left ventricular hypertrophy occurs, myocardial rupture may be more likely due to the already compromised myocardial substrate.Early treatment of subclinical amyloidosis, especially ATTR, should be considered to reduce complications such as this.

Source: Cardiology Research and Cardiovascular Medicine

DOI: 10.29011/2575-7083.100204