Left ventricular free wall rupture caused by myocardial ischemia without treatable atherosclerotic coronary disease: a case series

Abstract

Background: The clinical presentation of left ventricular free wall rupture (LVFWR) varies ranging from uneventful condition to congestive heart failure. Here we report two cases of LVFWR with different clinical presentation and notable outcome. A 53-year-old male presenting emergently with signs of myocardial infarction received immediate coronary angiography and thoracic CT-scan showing occlusion of the first marginal coronary branch without possibility of revascularization and minimal pericardial extravasation. Under ICU surveillance, LVFWR occurred 24 h later and was treated by pericardiocentesis and ECMO support followed by immediate uncomplicated surgical repair. Postoperative therapy-refractory vasoplegia and electromechanical dissociation caused fulminant deterioration and the early death of the patient. The second case is a 76-year old male brought to the emergency room after sudden syncope, clinical sings of pericardial tamponade and suspicion of a type A acute aortic dissection. Immediate CT-angiography excluded aortic dissection and revealed massive pericardial effusion and a hypoperfused myocardial area on the territory of the first marginal branch. Immediate sternotomy under mechanical resuscitation enabled removal of the massive intrapericardial clot and revealed LVFWR. After an uncomplicated surgical repair, an uneventful postoperative course, the patient was discharged with sinus rhythm and good biventricular function. One year after the operation, he is living at home, symptom free.

Discussion: Whereas the younger patient, who was clinically stable at hospital admission received delayed surgery and did not survive treatment, the older patient, clinically unstable at presentation, went into immediate surgery and had a flawless postoperative course. Thus, early surgical repair of LVFWR leads to best outcome and treating LVFWR as a high emergency regardless of the symptoms improve survival.

Keywords: Left ventricular rupture; Myocardial infarction; Resuscitation; Surgery.

Fig. 1

Preoperative screening for coronary disease in patient I Preoperative coronary angiography of patient I reveals occlusion of the first marginal branch (red arrow) with retrograde perfusion from the posterior interventricular branch (black arrow) of the left dominant coronary system (Fig. 1A), intact small right coronary system (Fig. 1B) and the suspicion of left ventricular pseudoaneuryms (red circle) without pericardial effusion of contrast substance (red arrow) in ventriculography (Fig. 1C)

Fig. 2

Preoperative thoracic CT-Angiogram Fig. 2A shows minimal pericardial effusion (red arrow) with suspicion of LVFWR of the first marginal branch (red circle) in patient I Fig. 2B shows relevant pericardial effusion (red arrow) and a hypocontrasted myocardial area of the first marginal branch (red circle) in patient II

Fig. 3

Preoperative screening for coronary disease in patient II Coronary thoracic CT-angiogram reconstruction of patient II reveals an intact main left coronary artery (Fig. 3A), suspicion (red arrow) of an occluded first marginal branch (Fig. 3B), and an intact right dominat coronary artery (Fig. 4C)