• Users Online: 302
  • Print this page
  • Email this page


 
 Table of Contents  
INTERESTING CASE REPORT
Year : 2020  |  Volume : 4  |  Issue : 2  |  Page : 213-216

Right Ventricular Free Wall Rupture: A Catastrophic Sequela of Myocardial Ischemia


Shri Ram Heart Center, Jodhpur, Rajasthan, India

Date of Submission11-Dec-2019
Date of Decision26-Jan-2020
Date of Acceptance28-Mar-2020
Date of Web Publication19-Aug-2020

Correspondence Address:
Dr. Bharat Rathi
E-1, 160, Phase 3, Roop Rajat Township, Pal Road, Jodhpur - 342 001, Rajasthan
India
Login to access the Email id

Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jiae.jiae_53_19

Rights and Permissions
  Abstract 

The case describes a rare mechanical complication of myocardial infarction in the form of right ventricular free wall rupture leading to cardiogenic shock and death. The patient had no cardiac high-risk factors and had short-lasting symptoms of the chest pain but presented in the emergency department in a semi-conscious state. The condition was diagnosed on transthoracic echocardiography and during the course of investigation, the patient instantaneously deteriorated and succumbed to the condition.

Keywords: Acute myocardial infarction, transthoracic echocardiography, ventricular free wall rupture


How to cite this article:
Rathi B, Inaniya R, Agarwal R. Right Ventricular Free Wall Rupture: A Catastrophic Sequela of Myocardial Ischemia. J Indian Acad Echocardiogr Cardiovasc Imaging 2020;4:213-6

How to cite this URL:
Rathi B, Inaniya R, Agarwal R. Right Ventricular Free Wall Rupture: A Catastrophic Sequela of Myocardial Ischemia. J Indian Acad Echocardiogr Cardiovasc Imaging [serial online] 2020 [cited 2020 Sep 30];4:213-6. Available from: http://www.jiaecho.org/text.asp?2020/4/2/213/292634


  Introduction Top


Coronary heart disease and related complications are the leading cause of death all over the word. The incidence of acute cardiac events continues to rise but with the advent of successful diagnostic and therapeutic interventions, the mortality has reduced significantly. Several mechanical complications of acute myocardial infarction (AMI) are known which include cardiogenic shock, ventricular septal rupture, acute mitral regurgitation, right ventricular infarction, and very rarely ventricular free wall rupture (VFWR). Besides, the mechanical complications, arrhythmic, and inflammatory complications are also well known. VFWR is one of the rarest and most catastrophic complications of AMI which almost always proves fatal if not diagnosed and treated in time.[1],[2] The condition can present with subtle symptoms and misguiding hemodynamic parameters in a previously asymptomatic and low-risk patient. We hereby present a case of the right VFWR (RVFWR) leading to cardiac tamponade, cardiogenic shock and death in an elderly male with no cardiac high-risk factors.


  Clinical Presentation Top


A 72-year-old male presented to our emergency department with complaints of chest pain for the past 10 h along with syncope and dizziness for the past 3 h. The patient was brought in a semi-conscious state and was poorly responding to verbal commands. There was no history of diabetes mellitus, hypertension, or dyslipidemia or history of chest pain or cardiac interventions in the past. On physical examination, the patient had tachycardia, blood pressure was 130/90 mm Hg, respiratory rate was 22/min, and oxygen saturation was 92%. Chest auscultation revealed no significant abnormality except that the heart sounds were feeble with no appreciable pericardial rub or murmur. Electrocardiography (ECG) showed ST depression in the anterior leads (V1, V2, and V3) with tachycardia (heart rate of 130 beats/min). To confirm the diagnosis of non-ST elevation myocardial infarction (NSTEMI), cardiac markers were sent and while waiting for the report of cardiac markers, the patient underwent computed tomography (CT) of the head because of the compromised neurological state. The CT head revealed no abnormality but the cardiac markers were markedly raised (Troponin I level was 25 ng/ml, and creatinine phosphokinase-muscle and brain (CPK-MB) was 194 IU/L), hence, the diagnosis of acute coronary syndrome (ACS) (NSTEMI) was established. His bedside transthoracic echocardiography (TTE) revealed regional wall motion abnormality of the inferior and posterior wall along with large pericardial effusion [Figure 1] with a smooth layer of echo-dense substance suggestive of blood [Figure 2] with ejection fraction of 40%. Right atrium (RA) and right ventricle (RV) were seen collapsed during the diastole [Figure 3] and in the right ventricular free wall, a slit-like defect was seen which was around 4–5 mm in size [Video 1 and [Figure 4]. There was no septal or apical rupture or any valvular regurgitation. Normal aortic and pulmonary valve flow was noted. Left atrial, right atrial, and RV diameters were normal. Cardiac tamponade was confirmed with the typical signs of systolic RA collapse and diastolic RV collapse. Repeat blood pressure was found to be 70/40 mmHg with worsening oxygen saturation of 86% on face mask. The patient was intubated immediately, and inotropic support was started with fluid replacement in view of cardiogenic shock. Within a short span of 15 min, the patient developed cardiac arrest and cardiopulmonary resuscitation was started but the patient could not be revived despite best of efforts.
Figure 1: Four-chambered view showing large pericardial effusion

Click here to view
Figure 2: Subcostal view showing large pericardial effusion toward the right ventricle free wall with layered echogenic substance in pericardial cavity suggestive of clotted blood

Click here to view
Figure 3: Four-chambered view showing the right atrium – the right ventricle collapse suggestive of cardiac tamponade

Click here to view
Figure 4: Subcostal four-chamber view (focused right ventricle chamber) showing site of tear in the right ventricle (marked by arrow)

Click here to view






  Discussion Top


RVFWR is a rare complication of AMI because of two reasons: (1) inferior wall MI is less common than anterior wall MI and (2) RVFWR is an extremely catastrophic complication of AMI, leading to death even before the patient reaches a specialty care, and hence, this entity may be underreported. Only a handful of cases of RVFWR as a consequence of an ischemic event are reported till date.[3],[4],[5] The outcome of RVFWR is mostly dismal in acute settings wherein it leads to hemopericardium and cardiogenic shock.[6] Rarely, RVFWR can present in subacute settings with no concerning symptoms or hemodynamic instability, as the cardiac tamponade develops slowly if the rupture site is small. The mechanism assumed for masquerading clinical picture is thought to be due to spontaneous sealing of the tear site which can occur secondary to clotting of the leaked blood, but the patient remains at risk of sudden cardiac events due to progressive bleeding in the pericardial sac. Following an untreated AMI, the ventricular free wall may rupture within a week's time secondary to wall ischemia and necrosis.[7] Typical patient profile for this complication is an elderly female with medical comorbidities such as hypertension, diabetes mellitus, and prior history of myocardial infarction or recent history of some cardiac intervention.[8]

Most patients with VFWR are symptomatic with chest pain, altered consciousness, syncope, dizziness, bradycardia, and hypotension secondary to depressed cardiac contractility due to pericardial effusion of blood from the site of rupture. Examination findings can be subtle in subacute settings but can deteriorate MB-creatine kinase in no time. Chest auscultation can reveal obscured or feeble heart sounds, systolic murmurs, and pericardial rub. Pohjola-Sintonen et al.[9] studied left ventricular rupture in 849 patients with AMI, they documented rupture in only 14 cases (1.7%) but it accounted for 14% of in-hospital mortality. Seven of the 14 ruptures occurred within 2 days and 10 within 4 days of the MB-creatine kinase determined the onset of infarction. The authors proposed that rupture was 9.2 times more likely to occur in patients with all of the following characteristics than in the remaining patients: (1) no history of previous angina or myocardial infarction, (2) ST segment elevation or signs of Q wave development on the initial ECG, and (3) peak MB-creatine kinase value (≥150 IU/L). They concluded that although these predictors are likely to be of little therapeutic value for free wall rupture since most patients with that complication die within minutes of its onset, they may aid in alerting physicians to the early diagnosis and timely surgical correction of ventricular septal rupture. In the present case, there was a short history of chest pain with NSTEMI and markedly raised CPK-MB levels.

Abreu Filho et al. observed 98 patients with ventricular rupture, of which only 5 (5.1%) were diagnosed in time to undergo surgical repair but only one patient could survive following surgical management.[10] Septal rupture and papillary muscle rupture is comparatively more frequent than free wall rupture following AMI.[11] RVFWR as described in the present case is eight times less common than the left ventricular rupture mainly because the inferior wall MI is less frequent than anterior wall MI, and the rupture site in the RV is difficult to localize on TTE.[12]

Echocardiography is the most ubiquitous and easily accessed investigation used these days in patients presenting with acute or chronic cardiac symptoms. Echocardiography has established its role in the diagnosis of VFWR with typical signs on imaging. Pericardial effusion is the most frequent echocardiographic finding, with a sensitivity as high as 100%; however, the specificity might be lower, because the causes of pericardial effusion after MI include pericarditis, hemorrhage from postinfarcted myocardium, coronary perforation, and myocardial rupture. It is important to note that the absence of effusion does not exclude the diagnosis of left ventricular free wall rupture (LVFWR). Other signs are echogenic layering in the pericardium that indicates a pericardial thrombus or clot, regional myocardial dilation, and an abnormally thin and akinetic myocardium. During color flow Doppler echocardiographic evaluation, a color flow jet through a visible wall defect is diagnostic of LVFWR but it can be absent in RVFWR, also the jet might be absent when pericardial thrombus plugs the rupture site.[13]

The management of VFWR is immediate surgery and repair of the defect. The surgical techniques involved are infarctectomy with patch repair, suturing of an overlay patch to the defect, or a patch-and-glue repair. Patients with a milder form of VFWR can be managed conservatively, but the bleeding can continue from the small tear and turn into a larger defect which can lead to emergency cardiac events such as massive tamponade and cardiac arrest. More recently with patch-and-glue techniques, avoiding cardiopulmonary bypass, short- and mid-term survival rates have improved to 60%–80% in studies of consecutive patients' series.[14]


  Conclusion Top


RVFWR is one of the rare complications of AMI and presents with almost 100% mortality if not diagnosed and treated in time. A high index of suspicion is needed in the settings of AMI with compromised hemodynamic status is the key to improved morbidity. The present case documents a very rare case of RVFWR in a patient with no comorbidities and NSTEMI. Echocardiography played a crucial role in the diagnosis but the patient deteriorated and succumbed to this catastrophe. These mechanical complications must be sought after in patients dying instantly in the settings of AMI, and the cardiac care team must be trained in handling such acute emergencies. The patients must be counseled about the warning symptoms of ACS so that they present in time, and coronary revascularization is timely achieved.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Babin-Ebell J, Saavedra-Blume JC, Urbanski P, Batz G, Diegeler A. Contained rupture of the aorta in acute Stanford type A aortic dissection causing right ventricular wall dissection. Thorac Cardiovasc Surg 2009;57:238-9.  Back to cited text no. 1
    
2.
Mohamed HA, Habib N, Dewar LR, Busse EF. Right ventricular wall hematoma due to thrombolytic therapy presenting as cardiac tamponade: A case report and review of literature. Can J Cardiol 2003;19:581-4.  Back to cited text no. 2
    
3.
Karhausen J, Nowak M, Couper GS, Formanek V, Mirakaj V, Locke A, et al. Right ventricular dissection diagnosed on transesophageal echocardiography. Anesth Analg 2008;106:412-4.  Back to cited text no. 3
    
4.
Ari H, Tiryakioglu O, Ari S, Bozat T, Koca V. A rare clinical entity: Ventricular septal rupture with right ventricular wall dissection after inferior myocardial infarction. Echocardiography 2009;26:211-3.  Back to cited text no. 4
    
5.
Basarici I, Erbasan O, Kemaloglu D, Arslan G, Bayezid O. Exceptional ventricular septal rupture associated with intramyocardial dissection throughout the right ventricle. Echocardiography 2010;27:460-5.  Back to cited text no. 5
    
6.
Tighe DA, Paul JJ, Maniet AR, Flack JE 3rd, Mannion JD, Rifkin RD, et al. Survival in infarct related intramyocardial dissection importance of early echocardiography and prompt surgery. Echocardiography 1997;14:403-8.  Back to cited text no. 6
    
7.
Sutherland FW, Guell FJ, Pathi VL, Naik SK. Postinfarction ventricular free wall rupture: Strategies for diagnosis and treatment. Ann Thorac Surg 1996;61:1281-5.  Back to cited text no. 7
    
8.
Amir O, Smith R, Nishikawa A, Gregoric ID, Smart FW. Left ventricular free wall rupture in acute myocardial infarction: A case report and literature review. Tex Heart Inst J 2005;32:424-6.  Back to cited text no. 8
    
9.
Pohjola-Sintonen S, Muller JE, Stone PH, Willich SN, Antman EM, Davis VG, et al. Ventricular septal and free wall rupture complicating acute myocardial infarction: Experience in the multicenter investigation of limitation of infarct size. Am Heart J 1989;117:809-18.  Back to cited text no. 9
    
10.
Abreu Filho CA, Dallan LA, Lisboa LA, Platania F, IgleÌzias JC, Cabral RH, et al. Surgical treatment of left ventricular free wall rupture after acute myocardial infarction. Rev Bras Cir Cardiovasc 2002;17:6-12.  Back to cited text no. 10
    
11.
Davis N, Sistino JJ. Review of ventricular rupture: Key concepts and diagnostic tools for success. Perfusion 2002;17:63-7.  Back to cited text no. 11
    
12.
Braunwald E, Zipes DP, Libby P. Heart Disease: a Textbook of Cardiovascular Medicine. Philadelphia: Elsevier Saunders; 2001. p. 1182.  Back to cited text no. 12
    
13.
Slater J, Brown RJ, Antonelli TA, Menon V, Boland J, Col J, et al. Cardiogenic shock due to cardiac free-wall rupture or tamponade after acute myocardial infarction: A report from the SHOCK Trial Registry. Should we emergently revascularize occluded coronaries for cardiogenic shock? J Am Coll Cardiol 2000;36:1117-22.  Back to cited text no. 13
    
14.
Nasir A, Gouda M, Khan A, Bose A. Is it ever possible to treat left ventricular free wall rupture conservatively? Interact Cardiovasc Thorac Surg 2014;19:488-93.  Back to cited text no. 14
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4]



 

Top
 
 
  Search
 
Similar in PUBMED
   Search Pubmed for
   Search in Google Scholar for
 Related articles
Access Statistics
Email Alert *
Add to My List *
* Registration required (free)

 
  In this article
Abstract
Introduction
Clinical Present...
Discussion
Conclusion
References
Article Figures

 Article Access Statistics
    Viewed86    
    Printed3    
    Emailed0    
    PDF Downloaded18    
    Comments [Add]    

Recommend this journal


[TAG2]
[TAG3]
[TAG4]