Myocardial infarction and left ventricular free wall rupture in a patient with a prior pericardiectomy.

A 59-year-old man with an inferolateral myocardial infarction and cardiogenic shock was found to have extensive intrathoracic hemorrhage in communication with the left ventricle. His remote pericardiectomy precluded hemopericardium and tamponade, and permitted the establishment of an unusual diagnosis and subsequent closure of the site of myocardial perforation.

Clinical utility of tissue Doppler imaging in patients with acute myocardial infarction complicated by cardiogenic shock.

BACKGROUND: Echocardiography is widely used in the management of patients with cardiogenic shock (CS). Left ventricular ejection fraction (EF) has been shown to be an independent predictor of survival in CS. Tissue Doppler Imaging (TDI) is a sensitive echocardiographic technique that allows for the early quantitative assessment of regional left ventricular dysfunction. TDI derived indices, including systolic velocity (S'), early (E') and late (A') diastolic velocities of the lateral mitral annulus, are reduced in heart failure patients (EF < 30%) and portend a poor prognosis. In CS patients, the application of TDI prior to revascularization remains unknown. OBJECTIVE: To characterize TDI derived indices in CS patients as compared to patients with chronic CHF. METHODS: Between 2006 and 2007, 100 patients were retrospectively evaluated who underwent echocardiography for assessment of LV systolic function. This population included: Group I) 50 patients (30 males, 57 +/- 13 years) with chronic CHF as controls; and Group II) 50 patients (29 males, 58 +/- 10 years) with CS. Spectral Doppler indices including peak early (E) and late (A) transmitral velocities, E/A ratio, and E-wave deceleration time were determined. Tissue Doppler indices including S', E' and A' velocities of the lateral annulus were measured. RESULTS: Of the entire cohort, the mean LVEF was 25 +/- 5%. Cardiogenic shock patients demonstrated significantly lower lateral S', E' and a higher E/E' ratio (p < 0.01), as compared to CHF patients. The in-hospital mortality in the CHF cohort was 5% as compared to the CS group with an in hospital mortality of 40%. In the subset of CS patients (n = 30) who survived, the mean S' at presentation was higher as compared to those patients who died in hospital (3.5 +/- 0.5 vs. 1.8 +/- 0.5 cm/s). CONCLUSION: Despite similar reduction in LV systolic function, CS patients have reduced myocardial velocities and higher filling pressures using TDI, as compared to CHF patients. Whether TDI could be a reliable tool to determine CS patients with the best chance of recovery following revascularization is yet to be determined.