Clinical History
No relevant prior history. The patient referred to the Emergency Department due to increasing typical chest pain, dispena, nausea. Myocardial enzymes were altered and electrocardiogram showed
infero-anterior Q wave with ST-segment elevation. The patient promptly underwent to successful percutaneous coronary intervention (PCI) with stent implantation of proximal left descending artery.
Imaging Findings
Three days after PCI he referred fatigue and dyspnea so that an echocardiography was performed depicting pericardial effusion and severe thinning of left ventricular apex wall with a suspicious
malacic area in the inferior apical segments. Cardiac Magnetic Resonance (MR) examination was requested due to the hypothesis of an impending heart rupture. Cardiac MR was performed with respiratory
and electrocardiographic trigger and with Gadolinium contrast administration. The examination confirmed the presence of myocardial thinning of heart apex (1 to 3 millimetres), especially of the
anterior and inferior segments (figure 1), with high signal intensity on T2 weighted images (figure 2) referable to oedema. At this latter level, cardiac MR showed a distension of the epicardium
(sub-epicardial aneurysm?) with no clear complete recognition of myocardial layer, compatible with myocardial impending rupture (figure 3). Moreover, during the injection of Gadolinium, an area of
hypo-enhancement was present with contrast extrusion in the epicardium (figure 4). Delayed enhancement images showed a transmural anterior and apical infarction with areas of microvascular
obstruction and with no evidence of clot neither thrombus (figure 5). Pericardial effusion was also present.
Discussion
Left ventricular wall rupture occurs in up to 7-10% of the hospital deaths following myocardial infarction and it is mainly associated
with postero-lateral myocardial infarction. It occurs 3 to 6 days after infarction and is rarely diagnosed ante-mortem, due to hemopericaridum and cardiac tamponade. Few cases are reported in
literature and most survivors are diagnosed during a period of ventricular pseudo-aneurysm prior to the development of hemodynamic compromise. The pathophysiology is believed to involve an initial
tearing of the endocardium with subsequent haemorrhage into the myocardial layer. The outer lining of the aneurysm is the epicardium, even if some myocardial cells may be present. The progression
of the break towards the epicardium with the developing of a sub-epicardial aneurysm represents a pre-rupture state. The diagnosis of these various steps can be made in selected cases with
different modalities: echocacardiography (with or without contrast media), left ventricular angiography, computed tomography and nowadays even with cardiac magnetic resonance. Clinical recognition
of this entity is imperative for life-saving surgical intervention. Contrast perfusion MR demonstrates contrast flow from the cavity of the left ventricle into the myocardium and epicardium and
delayed enhancement imaging permits to recognize both microvascular obstruction and the presence of transmural infarction, even if it is reported that heart rupture can be determined also by
non-transmural infarctions.
Differential Diagnosis List
Sub-epicardial aneurysm with impending rupture
Final Diagnosis
Sub-epicardial aneurysm with impending rupture
