277. Case Report: When Infarction Brings the Walls Down – Brigham and Women’s Hospital

CardioNerds (Amit and Dan) join Dr. Maria Pabon (cardiology fellow), Dr. Kevin Bersell (cardiology fellow), Dr. Saad Sultan Ghumman (interventional cardiology fellow), and Dr. Rhanderson Cardoso (cardiovascular imaging fellow) from Brigham and Women’s Hospital. Together, they explore a complex case of STEMI that was further complicated by ventricular free wall rupture. Additionally, Dr. Ajar Kochar, Program Director for Interventional Cardiology at Brigham and Women's Hospital, provides an insightful "ECPR" segment, adding a unique perspective to the case. Audio editing by CardioNerds Academy Intern, student doctor Chelsea Amo Tweneboah.



This is the case of a patient who presented with STEMI and was found to have a moderate pericardial effusion with echogenic material within the pericardial space concerning for thrombus. Urgent CTA/CT surgery was engaged due to concern for dissection, but no evidence of dissection, rupture or intramural hematoma was found. The patient underwent an urgent pericardiocentesis which yielded 350cc of hemorrhagic fluid, leading to an improvement in hemodynamic status. A coronary angiogram was performed which showed a 100% thrombotic occlusion of OM 1, the culprit lesion for the STEMI. Due to the possibility of a delayed STEMI and high suspicion for mechanical complication of MI, aspirin and IV cangrelor were chosen as the preferred antiplatelet strategy. However, cangrelor was held and cardiac surgery was consulted, as LV free wall rupture was suspected. The patient underwent urgent repair of the LV free wall rupture, with an uneventful post-op recovery and discharge on day 8 to cardiac rehab.



CardioNerds is collaborating with Radcliffe Cardiology and US Cardiology Review journal (USC) for a ‘call for cases’, with the intention to co-publish high impact cardiovascular case reports, subject to double-blind peer review. Case Reports that are accepted in USC journal and published as the version of record (VOR), will also be indexed in Scopus and the Directory of Open Access Journals (DOAJ).











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Pearls - When Infarction Brings the Walls Down - Brigham and Women’s Hospital




In the era of primary PCI, mechanical complications of MI are relatively rare.



Timely recognition using multi-modality imaging and prompt surgical intervention can result in favorable outcomes.



An approach that involves a Heart Team can be advantageous in optimizing outcomes in such complex cases.




Show Notes - When Infarction Brings the Walls Down - Brigham and Women’s Hospital




Incidence of post AMI LV free wall rupture:

0.1-1%





Risk factors for LV Free wall Rupture:

Older age



Female sex



Prior HTN



1st lateral or Anterior Wall MI





Protective factors towards free wall rupture:

LV hypertrophy



CHF



Hx of prior infarcts



Chronic ischemic heart disease



Early use of beta blockers post MI



Timely intervention





Incidence of Mortality associated with mechanical rupture related to AMI:

8-10%





When to suspect a mechanical complication of AMI:

AMI with shock/hypotension



New murmur



New pericardial effusion > 10mm on bedside echo





Other etiologies that can cause free wall rupture:

Trauma



Cardiac infection



Aortic dissection



Cardiac tumors



Infiltrative diseases



Iatrogenic from PCI or surgical procedures






References - When Infarction Brings the Walls Down - Brigham and Women’s Hospital




Varghese S, Ohlow MA. Left ventricular free wall rupture in myocardial infarction: A retrospective analysis from a single tertiary center. JRSM Cardiovasc Dis. 2019 Jan-Dec;8:2048004019896692. doi: 10.1177/2048004019896692. PMID: 31970072.



Pineda-De Paz, D.O.,