Left ventricular wall rupture due to subacute myocardial infarction and severe aortic regurgitation of the bioprosthetic aortic valve

    Authors

    Abstract

    **Background:** Left ventricular wall rupture is a rare complication of myocardial infarction, occurring in approximately 2% of cases. Mortality is extremely high unless early diagnosis is made and urgent surgical intervention is provided. (1, 2) **Case report:** 64-year old female patient with permanent atrial fibrillation and bioprosthetic aortic and mitral valve was admitted to Coronary Care Unit because of subacute myocardial infarction. She was on warfarin therapy due to secondary stroke prevention with an urgent INR of 2.7. Transthoracic echocardiography reveals hypokinesia of posterolateral wall, lobular pericardial effusion behind the posterolateral wall, and severe aortic stenosis and regurgitation of bioprosthetic valve. Urgent angiography showed occlusion of the obtuse marginal branch with spontaneous dissection of the distal segment without extravasation of contrast. Aortography showed severe aortic regurgitation without visible dissection. Because of high INR and pericardial effusion, we did not order a dual antiplatelet therapy. Control echocardiography exam verified pseudoaneurysm of ruptured posterolateral ventricular wall. Computerized tomography of the chest showed extravasation of contrast in the pericardium. For the purpose of surgical repair of left ventricular wall rupture and aortic valve replacement, patient was transferred to the Department of Cardiac surgery. During the hospitalization and transfer, patient was hemodynamically stable, without signs of tamponade. The patient died due to septic shock which occurred postoperatively. **Conclusion*:*** We believe that rupture is result of combination of myocardial ischemia and pressure load caused by severe aortic regurgitation. Left ventricular wall rupture is often fatal complication and mortality is higher in the patients with other structural heart disease such as severe combined aortic disease.

    Keywords

    aortic stenosis, myocardial infarction, aortic regurgitation

    DOI

    https://doi.org/10.15836/ccar2016.618

    Literature

    1. 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(3):424–6. https://pubmed.ncbi.nlm.nih.gov/16392235/
    2. Maganti K, Rigolin VH, Sarano ME, Bonow RO. Valvular heart disease: diagnosis and management. Mayo Clin Proc. 2010;85(5):483–500. https://doi.org/10.4065/mcp.2009.0706
    Cardiologia Croatica
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    Left ventricular wall rupture due to subacute myocardial infarction and severe aortic regurgitation of the bioprosthetic aortic valve

    Extended Abstract
    Issue12
    Published
    Pages618
    PDF via DOIhttps://doi.org/10.15836/ccar2016.618
    aortic stenosis
    myocardial infarction
    aortic regurgitation

    Authors

    Domagoj Mišković*ORCIDGeneral Hospital “Dr. Josip Benčević”, Slavonski Brod, Croatia
    Irzal HadžibegovićORCIDGeneral Hospital “Dr. Josip Benčević”, Slavonski Brod, Croatia
    Božo VujevaORCIDGeneral Hospital “Dr. Josip Benčević”, Slavonski Brod, Croatia
    Marijana Knežević PravečekORCIDGeneral Hospital “Dr. Josip Benčević”, Slavonski Brod, Croatia
    Đeiti PrvulovićORCIDGeneral Hospital “Dr. Josip Benčević”, Slavonski Brod, Croatia
    Krešimir GabaldoORCIDGeneral Hospital “Dr. Josip Benčević”, Slavonski Brod, Croatia
    Martina MenegoniORCIDGeneral Hospital “Dr. Josip Benčević”, Slavonski Brod, Croatia

    *Correspondence email: domagoj1304@gmail.com

    Abstract

    **Background:** Left ventricular wall rupture is a rare complication of myocardial infarction, occurring in approximately 2% of cases. Mortality is extremely high unless early diagnosis is made and urgent surgical intervention is provided. (1, 2) **Case report:** 64-year old female patient with permanent atrial fibrillation and bioprosthetic aortic and mitral valve was admitted to Coronary Care Unit because of subacute myocardial infarction. She was on warfarin therapy due to secondary stroke prevention with an urgent INR of 2.7. Transthoracic echocardiography reveals hypokinesia of posterolateral wall, lobular pericardial effusion behind the posterolateral wall, and severe aortic stenosis and regurgitation of bioprosthetic valve. Urgent angiography showed occlusion of the obtuse marginal branch with spontaneous dissection of the distal segment without extravasation of contrast. Aortography showed severe aortic regurgitation without visible dissection. Because of high INR and pericardial effusion, we did not order a dual antiplatelet therapy. Control echocardiography exam verified pseudoaneurysm of ruptured posterolateral ventricular wall. Computerized tomography of the chest showed extravasation of contrast in the pericardium. For the purpose of surgical repair of left ventricular wall rupture and aortic valve replacement, patient was transferred to the Department of Cardiac surgery. During the hospitalization and transfer, patient was hemodynamically stable, without signs of tamponade. The patient died due to septic shock which occurred postoperatively. **Conclusion*:*** We believe that rupture is result of combination of myocardial ischemia and pressure load caused by severe aortic regurgitation. Left ventricular wall rupture is often fatal complication and mortality is higher in the patients with other structural heart disease such as severe combined aortic disease.

    Literature

    1. 1.
      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(3):424–6.PubMed
    2. 2.
      Maganti K, Rigolin VH, Sarano ME, Bonow RO. Valvular heart disease: diagnosis and management. Mayo Clin Proc. 2010;85(5):483–500.DOI