Successful Surgical Treatment of a Rare Case of Acute Isolated Right Ventricle Wall Rupture Caused by Distal Circumflex Coronary Artery Occlusion

Abstract We describe a rare case of isolated right ventricular inferior free-wall rupture and cardiogenic shock caused by occlusion of the distal left circumflex coronary artery. Our case highlights the central role of transthoracic echocardiography in identifying unexpected conditions that can guide management - in our case involving early surgical intervention, thus leading to favourable patient outcomes.

Appropriate surgical repair of ventricular free wall rupture after infarction: a case report

Abstract Ventricular free wall rupture is a fatal mechanical complication of acute myocardial infarction. In some cases it can be represented as subacute clinic and may not cause death in a few minutes. Acute pseudo-aneurysms are extremely unstable and bound to fatal rupture. Herein we report a male patient who suffered dyspnea and mild chest pain, 4 weeks after acute ST-segment elevation myocardial infarction.

Rotura miocárdica de ventrículo izquierdo secundaria a infarto agudo de miocardio / Myocardial rupture of left ventricle secondary to myocardial infarction

RESUMEN Fundamento: la rotura miocárdica es una complicación rara del infarto agudo de miocardio con una incidencia global de alrededor del 6,2 %. Objetivo: caracterizar los fallecidos por infarto agudo de miocardio con la rotura de pared de ventrículo izquierdo. Métodos: se realizó un estudio retrospectivo, descriptivo y observacional, en el cual se analizaron los fallecidos con diagnóstico de causa directa de muerte: taponamiento cardíaco por hemopericardio, rotura de miocardio e infarto agudo de miocardio. Resultados: de 877 infartos agudos de miocardio diagnosticados entre 2010 a 2018, 16 de ellos presentaron rotura de pared miocárdica de los cuales 68,8 % eran del masculino. El hábito de fumar fue el factor de riesgo predominante. Solo en un 35,7 % se realizó el diagnóstico clínico correcto de IAM y en ninguno de los casos fue planteado el diagnóstico de rotura de miocardio o taponamiento cardíaco por hemopericardio. La región anatómica del corazón donde con mayor frecuencia se localizaron las roturas de miocardio fue en la pared posterior. Conclusiones: la rotura de la pared de miocardio es una complicación del infarto poco frecuente pero catastrófica con una mortalidad elevada, sin embargo, esta puede reducirse si el cuadro clínico es sospechado, y se realiza un diagnóstico precoz con instauración de medidas de apoyo para mantener la estabilidad hemodinámica.

ABSTRACT Background: myocardial rupture is a rare complication of acute myocardial infarction with an overall incidence of around 6.2 %. Objective: to characterize the deaths due to acute myocardial infarction with the rupture of the left ventricle wall. Methods: a retrospective, descriptive and observational study was carried out in which the deceased were analyzed with a diagnosis of direct cause of death: cardiac tamponade due to hemopericardium, myocardial rupture and acute myocardial infarction. Results: of 877 acute myocardial infarcts diagnosed between 2010 and 2018, 16 of them had myocardial wall rupture of which 68.8% were male. The habit of smoking was the predominant risk factor. Only in 35.7 % the correct clinical diagnosis of AMI was made and in none of the cases was the diagnosis of myocardial rupture or cardiac tamponade due to hemopericardium. The anatomical region of the heart where myocardial ruptures were most frequently located was in the posterior wall. Conclusions: rupture of the myocardial wall is a rare but catastrophic complication of infarction with a high mortality, however, this can be reduced if the clinical picture is suspected, and an early diagnosis is made with the introduction of support measures to maintain hemodynamic stability.

Treatment experience of cardiac rupture in patients with acute myocardial infarction / 中华心血管病杂志

Objective@#To analyze the treatment results of cardiac rupture in patients with acute myocardial infarction (AMI) .@*Method@#Clinical data of 6 with cardiac rupture after AMI, who were hospitalized in our hospital from June 2015 to June 2017, were retrospectively analyzed,and the clinical manifestations, methods of treatment and outcomes were investigated.@*Results@#Cardiac function classification was Killip class Ⅱin all patients. There were 3 massive anterior wall myocardial infarction, 2 anterior wall myocardial infarction,and 1 inferior myocardial infarction. There were 4 patients with ventricular septal defect, 1 patient with rupture of papillary muscle,and 1 patient with left ventricular free wall rupture.All patients received continuous infusion of vasoactive medicines and treated with intra-aortic balloon pump(IABP), 2 patients (1 patient accepted operative treatment,and 1 patient received conservative treatment) were treated with extracorporeal membrane oxygenation (ECMO), mechanical ventilation,and continuous renal replacement therapy(CRRT).Three patients received surgical repair,1 case was supported by IABP, 1 case supported by ECMO,CRRT,and IABP,and 1 case did not use IABP or ECMO post operation. All 3 surgically treated patients recovered successfully and were discharged from hospital.Meanwhile, in the other 3 patients treated conservatively, 2 patients died in the hospital and 1 patient was discharged according to own will.@*Conclusion@#On the basis of vasoactive medicines and IABP, surgery repair is a feasible option for cardiac rupture patients secondary to AMI,and ECMO may improve the perioperative state in these patients.

Rupture of Right Ventricular Free Wall Following Ventricular Septal Rupture in Takotsubo Cardiomyopathy with Right Ventricular Involvement

Most patients diagnosed with takotsubo cardiomyopathies are expected to almost completely recover, and their prognosis is excellent. However, complications can occur in the acute phase. We present a case of a woman with takotsubo cardiomyopathy with right ventricular involvement who developed a rupture of the right ventricular free wall following ventricular septal rupture, as a consequence of an acute increase in right ventricular afterload by left-to-right shunt. Our case report illustrates that takotsubo cardiomyopathy can be life threatening in the acute phase. Ventricular septal rupture in biventricular takotsubo cardiomyopathy may be a harbinger of cardiac tamponade by right ventricular rupture.

Symmetrical peripheral gangrene complicating ventricular pseudoaneurysm: a report of an unusual case and a brief review of the literature

Abstract Symmetrical peripheral gangrene is an ischemic necrosis simultaneously involving the distal portions of two or more extremities without any proximal arterial obstruction or vasculitis. It may occur as a result of a large number of infectious and non-infectious causes. A few cases of symmetrical peripheral gangrene associated with cardiac disease have been described in the literature. We describe a case of symmetrical peripheral gangrene complicating ventricular pseudoaneurysm, probably a hitherto unreported occurrence. In this report, we sought to emphasize the importance of cardiac evaluation while dealing with a case of symmetrical peripheral gangrene.

Masa en cuello secundaria a electrodo de estimulación cardiaca abandonado / Neck mass secondary to an abandoned pacing lead

Mujer de 70 años de edad, con historia de un electrodo de estimulación cardiaca abandonado, que genera: un trastorno de la deglución y una deformidad estética que la hacen consultar en múltiples oportunidades. A pesar de que se planteó la opción del retiro quirúrgico, se logró una extracción endovascular por la tracción de un electrodo. Describimos la utilidad del eco intracardiaco y el catéter ENSnare®, para la extracción de los electrodos en este tipo de casos.

70-year-old woman with a history of an abandoned pacing lead who developed a deglutition disorder and an aesthetic deformity that made her consult in multiple specialties. Even though surgical removal was considered, endovascular extraction was accomplished with the traction of the lead. We describe the usefulness of the intracardiac echocardiography and the ENSnare® catheter for this type of lead extractions.

Trauma cardiaco cerrado / Blunt cardiac trauma

El trauma cardiaco constituye una de las primeras causas de mortalidad en la población general. Requiere alto índice de sospecha en trauma cerrado severo, mecanismo de desaceleración y en presencia de signos indirectos como: equimosis, huella del volante o del cinturón en el tórax anterior. Las lesiones incluyen: conmoción cardiaca, ruptura cardiaca, lesión cardiaca indirecta como la trombosis coronaria aguda, lesión aórtica, lesión del pericardio y herniación cardiaca. Entre las manifestaciones clínicas están: la angina refractaria a nitratos, el dolor pleurítico, la hipotensión arterial, la taquicardia, la ingurgitación yugular que aumenta con la inspiración, el galope por tercer ruido, el frote pericárdico, los soplos de reciente aparición, los estertores crepitantes por edema pulmonar. El electrocardiograma es el primer eslabón en el algoritmo diagnóstico con hallazgos como: la taquicardia sinusal, los complejos ventriculares prematuros, la fibrilación auricular, el bloqueo de rama derecha y los bloqueos auriculoventriculares. La radiografía de tórax ayuda a descartar lesiones adicionales óseas y pulmonares. La troponina I tiene un valor predictivo negativo del 93% para el trauma cardiaco, otras enzimas como la creatina quinasa total y la creatina quinasa fracción MB son menos específicas. El ecocardiograma está indicado en caso de hipotensión persistente, electrocardiograma con alteraciones o falla cardiaca aguda. El tratamiento incluye la estabilización inicial y un manejo específico de las lesiones. Entre las complicaciones se incluyen: el taponamiento cardiaco, la contusión miocárdica, el síndrome coronario agudo, las arritmias cardíacas y la lesión aórtica. El pronóstico se determina en mayor medida por los signos vitales al ingreso y la presencia de paro cardiaco durante el abordaje inicial.

Cardiac trauma is one of the primary causes of death amongst general population. It requires a high degree of suspicion of severe blunt trauma, deceleration mechanism and presence of indirect signs, such as ecchymosis and steering wheel or seatbelt marks in the anterior chest wall. Injuries include: cardiac concussion, heart rupture, indirect cardiac injury, such as acute coronary thrombosis, aortic injury, pericardial injury and cardiac herniation. The clinical signs and symptoms include: angina refractory to nitrates, pleuritic pain, hypotension, tachycardia, jugular venous distention that increases on inspiration, S3 gallop, pericardial rub, new murmur or crepitant rales due to pulmonary edema. The electrocardiogram is the first link in the diagnostic algorithm leading to findings such as sinus tachycardia, premature ventricular complexes, atrial fibrillation, right bundle branch block and atrioventricular block. Chest X-rays help to rule out other pulmonary or bone injuries. Troponin I has a negative predictive value of 93% for cardiac trauma; other less specific cardiac enzymes are creatine kinase and creatine kinase-MB. Echocardiogram is indicated in presence of persistent hypotension, abnormal ECG results or acute heart failure. The treatment includes initial stabilization and specific management of the injuries. Some complications may include: cardiac tamponade, myocardial contusion, acute coronary syndrome, cardiac arrhythmias and aortic injury. The prognosis of the patient depends on the vital signs at the time of arrival at the emergency department and the presence of cardiac arrest during the initial approach.

The diagnosis and treatment of acute myocardial infarction complicated with left ventricular wall rupture:a report of three cases / 天津医药

Objective To investigate the diagnosis and treatment in patients with acute myocardial infarction (AMI) and complicated left ventricular wall rupture (LVWR). Methods A retrospective analysis was made on the clinical features, diagnosis and successful treatment in three AMI patients with LVWR from December 2015 to April 2016. Results Three cases were included in this study. Case 1, the mesh like cardiac rupture after AMI was diagnosed by ultrasonic Doppler. Emergency revascularization was performed due to the combined cardiac shock, and the infarct related artery was opened. The vasoactive drugs were used after revascularization to reduce ventricular pressure load and volume load in the haemodynamic monitoring, and anticoagulation, antiplatelet agents were less used or discontinued to promote local thrombus healing of ventricular rupture. Case 2 was a recurrent myocardial infarction patient. LVWR was diagnosed by ultrasonic Doppler one day after emergency operation. The ruptured ventricular wall was encapsulated by thrombus. The drug therapy was effective in hemodynamic monitoring. LVWR was further confirmed by cardiac CT after clinical stabilization. Case 3 was diagnosed LVWR by ultrasonic Doppler four days after AMI. Because the ruptured ventricular wall was limited by incompletely organized thrombus, and the haemodynamic condition was stable, selective surgical repair of rupture after coronary angiography was performed. Conclusion The effective drug therapy combined with percutaneous coronary intervention and surgical repair can reduce the risk of death in patients with LVWR after AMI.

Gastric Mucormycosis Followed by Traumatic Cardiac Rupture in an Immunocompetent Patient / 대한소화기학회지

Gastric mucormycosis is a rare and life-threatening fungal disease, caused by fungus in the order Mucorales. While rhino-cerebral and pulmonary forms are common, gastric mucormycosis is an uncommon site for the disease. We diagnosed gastric mucormycosis in a 41-year-old female who had severe multiple trauma, including cardiac rupture, due to a traffic accident. Eighteen days after hospitalization, she passed 800 mL of melena over one day. We performed upper esophagogastroduodenoscopy (EGD) and found a huge gastric ulcer with bleeding. Histopathological examination identified non-septated and right-angled branching fungal hyphae, and we diagnosed gastric mucormycosis. We recommended total gastrectomy to her but she refused the operation, so she was treated with liposomal amphotericin B for 53 days. After two months of treatment with liposomal amphotericin B, we again performed EGD and found a healed gastric ulcer. After four months, with another EGD, we found that the gastric mucormycosis was completely healed.

Successful Healing of the Myocardial Rupture Complicated by the Occlusion of a Single Diagonal Branch / 대한내과학회지

Myocardial rupture is a rare but lethal complication of myocardial infarction. Immediate conservative management is critical, but surgery should be considered if the patient's hemodynamic state and degree of hemopericardium do not improve after pericardiocentesis. In this case, a 54-year old patient without underlying disease came to the emergency after experiencing chest pain for two weeks with suddenly aggravated severe dyspnea. The patient was found to have a hemopericardium with cardiac tamponade, so pericardiocentesis was immediately executed. Transthoracic echocardiogram revealed akinesia of the left ventricular muscle and focal wall thinning. The patient was diagnosed with complete occlusion of a single diagonal branch and ventricular free wall rupture using a coronary computed tomography scan. After conservative treatment, vital signs and cardiac function stabilized, and there was no definitive sequela. This case is clinically significant because myocardial rupture, a lethal complication of myocardial infarction, was successfully managed with non-surgical, conservative treatment.

Cardiac Rupture of the Junction of the Right Atrium and Superior Vena Cava in Blunt Thoracic Trauma / 대한중환자의학회지

Cardiac rupture following blunt thoracic trauma is rarely encountered, since it commonly causes death at the scene. With advances in critical care, blunt cardiac rupture has been successfully treated with well-organized team approach including an emergency physician, anesthesiologist, and cardiac surgeon. We encountered a patient with blunt cardiac rupture of the junction of the superior vena cava and right atrium that extended 7 cm to the right ventricular junction. The patient was successfully resuscitated after a closed thoracostomy and pericardiocentesis with fluid loading. Cardiac injury was repaired via mid-sternotomy without cardiopulmonary bypass. The patient recovered without complications and was discharged on the 7th day after surgery.

Cardiac Rupture of the Junction of the Right Atrium and Superior Vena Cava in Blunt Thoracic Trauma / 대한구급학회지

Cardiac rupture following blunt thoracic trauma is rarely encountered, since it commonly causes death at the scene. With advances in critical care, blunt cardiac rupture has been successfully treated with well-organized team approach including an emergency physician, anesthesiologist, and cardiac surgeon. We encountered a patient with blunt cardiac rupture of the junction of the superior vena cava and right atrium that extended 7 cm to the right ventricular junction. The patient was successfully resuscitated after a closed thoracostomy and pericardiocentesis with fluid loading. Cardiac injury was repaired via mid-sternotomy without cardiopulmonary bypass. The patient recovered without complications and was discharged on the 7th day after surgery.

Right Ventricular Rupture Caused by Prolonged Cardiopulmonary Resuscitation after Sudden Cardiac Arrest / 대한내과학회지

A 46-year-old male arrived at the emergency department with acute dyspnea. On the way to the hospital, heart massage was performed in the ambulance due to asystole on electrocardiography. After 2 hr of resuscitation, sinus rhythm was restored. Extracorporeal life support and an intra-aortic balloon pump were applied due to cardiogenic shock, but the patient showed sustained hypotension. Echocardiography showed moderate pericardial effusion with physiological evidence of cardiac tamponade; emergency pericardiocentesis was performed, which produced bloody pericardial fluid. An explorative sternotomy revealed a massive hematoma in the mediastinum and right ventricular (RV) free wall rupture. After primary repair, echocardiography showed improved left ventricular systolic function and the patient was stable clinically. This case presents RV free wall rupture as an unusual complication of prolonged heart massage. Heart rupture should be considered in hemodynamically unstable patients after prolonged heart massage.

Contained cardiac rupture: An autopsy case.

Rupture of the myocardium due to myocardial infarction is often fatal but when such patients survive, they present with a pseudoaneurysm where the defect is sealed by the pericardium preventing the complete rupture. This is described as a ‘contained myocardial rupture’. We describe here a case of left ventricular contained myocardial rupture following an acute myocardial infarction.

Surgical Treatment of Post-Infarction Left Ventricular Free Wall Rupture: Three Cases Review

Left ventricular free wall rupture (LFWR) is rare, but is one of the most serious complications of myocardial infarction and is associated with high mortality. Several operative techniques have been attempted, but early diagnosis and prompt surgical management are crucial for a positive patient outcome. We report three cases of LFWR successfully treated with surgical methods.

Surgical treatment of left ventricular rupture after mitral valve replacement / 中华胸心血管外科杂志

Objective To evaluate the causes,treatment,and prevention of left ventricular rupture after mitral valvereplacement.Methods From May 1981 to November 2010,11 cases occurred in 4 male and 7 female patients aged 28 - 71 years old.There were 2 cases of New York Heart Association (NYHA) functional class Ⅱ and 9 cases of class Ⅲ.Echocardiography showed that the left ventricular end diastolic internal diameter (LVEDI) was 32 -62 mm.Results Rupture probably occurs after endocardial damage to a thin myocardium that has lost the internal buttress of the subvalvar apparatus.With the rise in intraventricular pressure at the end of bypass blood dissects into the myocardium,resulting in a large haematoma and eventual rupture.According to the onset of ruptures,there were 4 cases of delayed rupture which occured at several hours till days post operation after the patients had been back in the ICU,and 7 cases of early ruptur,which occured at the early stage of surgery,while the patient was still in the operation room.There were no cases of ruptures.The types of the ruptures were identified by operation or necropsy as 5 cases of type Ⅰ,4 cases of type Ⅱ,and 2 cases of type Ⅲ.Four patients were saved after emergency treatment,and 7 died.Conclusion It is difficult to repair left ventricle rupture,but effective prevention for onset can decrease its occurrence.The risk factors for left ventricular ruptures are female,advanced age,pathological changes characterized by mitral stenosis,small left ventricle (LVEDD ＜ 35 mm),and low weight( ＜50 kg ).The following actions raise the risk of let ventricular rupture.Isolated replacement of the mitral valve than after double valve replacement or mitral valve replacement and coronary artery bypass graft; aggressive removal of calcification at the mitral valve; undue selection and replacement of mitral valve prostheses; large size of prosthetic valve with a high bioprosthetic angle in particular; deep sutures at the valve ring; aggressive traction or removal of papillary muscle,hematoma,and heart move.Also we should continue correcting unstable hemodynamic especially with very high blood pressure.Once left ventricular rupture occurs,extracorporeal circulation should be established as soon as possible,and direet suture or intracardiac and extracardiac repair suited to actual conditions are reliable ways to save the patient's life.