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Cardiovascular Disease |

Abdominal Pain, An Unusual Presentation of Ventricular Rupture

Mohamad Zetir, MD
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Mayo Clinic Florida, Oviedo, FL


Chest. 2015;148(4_MeetingAbstracts):75A. doi:10.1378/chest.2255850
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Abstract

SESSION TITLE: Cardiovascular Disease Student/Resident Case Report Posters

SESSION TYPE: Student/Resident Case Report Poster

PRESENTED ON: Tuesday, October 27, 2015 at 01:30 PM - 02:30 PM

INTRODUCTION: Myocardial wall rupture is a rare, but often lethal complication of myocardial infarction (MI). It occurs within two weeks in over 90% of cases (1). Hemodynamic stabilization and immediate surgery should be performed to make survival possible.

CASE PRESENTATION: A 63-year-old man with a history of hypertension and diabetes mellitus, but no prior history of cardiac disease or chest pain presented with severe abdominal pain that started one hour earlier. The pain was periumbilical, radiating to the back, associated with diaphoresis and shortness of breath. His blood pressure was 60/30 mmHg, heart rate was 89 bpm, and oxygen saturation was 83% on room air. On exam the patient was in severe distress, lying supine, aggravated by any movement. Cardiovascular exam revealed regular rate and rhythm, no murmurs, faint peripheral pulses. Abdomen was soft and non-distended, with significant tenderness to palpation in both lower quadrants. Laboratory studies yielded hemoglobin of 14.8 mg/dL and troponin T of 0.79 ng/ml. EKG suggested inferior and lateral subendocardial injury. CTA of the chest showed no aortic dissection. Echocardiogram showed moderate circumferential pericardial effusion. Norepinephrine was required for pressure support. Emergent cardiac catheterization showed coronary disease, however not sufficient to explain the presentation. Left ventriculogram revealed a contained myocardial rupture. A pericardial window was created and 500 ml of blood was removed from the pericardium. The patient was managed on ECMO postoperatively.

DISCUSSION: Myocardial rupture and cardiogenic shock are serious and often lethal complications of MI. Left ventricular wall rupture leads to hemopericardium and death from cardiac tamponade. Transthoracic echocardiography can facilitate the diagnosis. Emergent pericardiocentesis may help confirm the diagnosis and transiently relieve the tamponade. Risk factors for developing ventricular rupture after an MI include absence of history of angina or prior MI, presence of ST-segment elevation or Q wave development on the initial electrocardiogram, which result from the lack of collateral blood flow. Larger size MI such as transmural MI increases the likelihood of myocardial rupture. Ventricular rupture is rarely seen in a hypertrophied ventricle or in an area of extensive collateral circulation.

CONCLUSIONS: Patients with signs and symptoms of the left ventricular wall rupture require an immediate bedside echocardiogram and pericardiocentesis followed by emergent surgery, if confirmed. Rapid recognition and treatment can lead to survival. In one study, 25 of 33 patients (76%) with subacute ventricular rupture survived the surgical procedure; 16 patients (48%) were long-term survivors (2).

Reference #1: Batts KP et al. Postinfarction rupture of the left ventricular free wall. Hum Pathol 1990; 21:530.

Reference #2: López-Sendón J, et al. Diagnosis of subacute ventricular wall rupture after acute myocardial infarction. J Am Coll Cardiol 1992; 19:1145.

DISCLOSURE: The following authors have nothing to disclose: Mohamad Zetir

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