© 2014, Wiley Periodicals, Inc. DOI: 10.1111/echo.12508
Echocardiography
CASE REPORTS Section Editor: Brian D. Hoit, M.D.
Left Ventricular Rupture after Embolic Myocardial Infarction Due to Mitral Valve Endocarditis Thibault Caspar, M.D.,* Xavier Delabranche, M.D., Ph.D.,† Jean-Philippe Mazzucotelli, M.D., Ph.D.,‡ Hafida Samet, M.D.,* Olivier Morel, M.D., Ph.D.,* and Patrick Ohlmann, M.D., Ph.D.* *Department of Cardiology, University Hospital of Strasbourg, Strasbourg, France; †Intensive Care Unit, University Hospital of Strasbourg, Strasbourg, France; and ‡Cardiac Surgery, University Hospital of Strasbourg, Strasbourg, France
We report a very rare case of a 43-year-old patient with fatal left ventricular subepicardial aneurysm rupture complicating embolic myocardial infarction due to mitral valve infective endocarditis. (Echocardiography 2014;31:E104–E106) Key words: left ventricular rupture, subepicardial aneurysm, infective endocarditis, embolic myocardial infarction A 43-year-old man with a history of heroin addiction treated with buprenorphin was admitted to local hospital for fever and fatigue. Infective mitral valve endocarditis was diagnosed on transthoracic and transesophageal echocardiography (Philips, Amsterdam, The Netherlands) (Fig. 1) showing 2 vegetations on each mitral leaflet, with a perforation of the anterior mitral leaflet and moderate regurgitation. Blood cultures were positive for methicillin-sensitive Staphylococcus aureus. The patient was treated with intravenous antibiotics (oxacillin and gentamicin). Systemic emboli were found in the toes on clinical examination, and in brain, spleen, and kidneys on computed tomography (General Electric, Fairfield, CT, USA). Six days later, he suddenly experienced chest pain, with ST-segment elevation in V3–V4 leads. Coronary angiography (Philips) was emergently performed showing distal left anterior descending artery occlusion (Fig. 2). Other coronary arteries were normal. The patient was referred to our tertiary hospital for surgical treatment of mitral valve endocarditis. Mitral valve repair was performed on day 10 after initial diagnosis of infective endocarditis. The first postoperative days were uneventful with clinical improvement of the patient’s status. Two weeks after surgery, chest CT scan showed a left ventricular apical aneurysm, with a narrow neck and a thin wall made of necrotic myocarAddress for correspondence and reprint requests: Thibault ^ pitaux Universitaires de Strasbourg, Po ^ le Caspar, M.D., Ho ^pital Civil, 1, m edico-chirurgical cardio-vasculaire, Nouvel Ho ^ pital, F- 67091 Strasbourg Cedex, France. Place de l’Ho Fax: +33 (0) 369 551 879; E-mail: [email protected]
E104
dium, consistent with subepicardial aneurysm (Figs. 3 and 4) and complicating prior embolic myocardial infarction. A few days later, the patient experienced acute severe dyspnea with jugular venous distension and low blood pressure. Immediate echocardiography revealed a left ventricular apical wall rupture with pericardial effusion and right ventricular compression (Fig. 5). The patient was immediately transferred to cardiac surgery operating room with major hemodynamic instability and electromechanical dissociation. Cardiopulmonary resuscitation was performed for 15 minutes before extra corporeal circulation was initiated after open chest surgery. A voluminous ruptured subepicardial aneurysm was evidenced in the left ventricular apex with a large myocardial defect (30 mm). There was no evidence of endocardial or myocardial tissue
Figure 1. Transesophageal echocardiography: mid-esophageal mitral commissural view showing voluminous vegetation (arrow) on posterior mitral valve leaflet (P3 segment). LA = left atrium; LV = left ventricle; LAA = left atrial appendage.
Endocarditis, Embolic MI, Myocardial Rupture
Figure 2. Left coronary angiogram showing distal left anterior descending artery occlusion (arrow).
Figure 4. Computed tomography with 3D volume rendering reconstruction showing left ventricle apical aneurysm (arrow). LV = left ventricle; RV = right ventricle; AO = aorta; PA = pulmonary artery.
Figure 3. Chest computed tomography showing the four heart chambers and a left ventricular subepicardial apical aneurysm (arrow) with a diameter of 44 mm and a thin myocardial layer. LA = left atrium; LV = left ventricle; RA = right atrium; RV = right ventricle.
infection, and no pus was found in the pericardial cavity. Hemopericardium was evacuated, and surgical cardiomyoplasty using a pericardial patch was performed allowing temporary hemodynamic stabilization under epinephrine and norepinephrine infusion. However, later evolution was unfavorable despite extracorporeal life support and continuous renal replacement therapy and the patient died 2 weeks after surgery. Left ventricular rupture complicates approximately 2% of myocardial infarctions and accounts for 16% of hospital deaths after infarction.1 It is a diagnostic and therapeutic challenge, as it requires emergency surgical treatment. Echocardiography is of paramount importance to establish the diagnosis. The present case illustrates this rare complication with unfavorable
Figure 5. Transthoracic echocardiographic apical fourchamber view showing a large myocardial defect (arrow) in the left ventricular apical wall and a communication between the left ventricle and the pericardial cavity (ruptured aneurysm). LA = left atrium; LV = left ventricle; RA = right atrium; RV = right ventricle.
clinical course despite immediate surgery in a patient with embolic myocardial infarction due to mitral valve endocarditis. Myocardial infarction due to coronary artery septic embolization is very rare, with an estimated incidence of 0.3%, and is associated with a high risk of mortality.2 Moreover, subepicardial aneurysm is an uncommon complication of myocardial infarction. It is an abrupt interruption of the myocardium, with E105
Caspar, et al.
typically a narrow neck connecting the ventricular cavity with the aneurysmal pouch. The aneurysmal wall comprised epicardium with or without a thin myocardial layer and the risk of its rupture is high.3,4 Rupture of left ventricle in the clinical situation of an embolic myocardial infarction has only been reported sporadically in the literature,5 with to the best of our knowledge no previous publication of such echocardiography images. References 1. Shapira I, Isakov A, Burke M, et al: Cardiac rupture in patients with acute myocardial infarction. Chest 1987; 92:219–223.
E106
2. Fabri J Jr, Issa VS, Pomerantzeff PM, et al: Time-related distribution, risk factors and prognostic influence of embolism in patients with left-sided infective endocarditis. Int J Cardiol 2006;110:334–339. 3. Yang HS, Shah SB, Sweeney JP, et al: Subepicardial aneurysm evaluated by multiplane 2D and real-time 3D volumetric transesophageal echocardiography. Circ Cardiovasc Imaging 2008;1:171–172. 4. Roldan FJ, Vargas-Barron J, Aguirre-Espinosa M, et al: Subepicardial aneurysm: Echocardiographic evaluation and evolution. Echocardiography 2009;26:504–507. 5. Tayama E, Chihara S, Fukunaga S, et al: Embolic myocardial infarction and left ventricular rupture due to mitral valve endocarditis. Ann Thorac Cardiovasc Surg 2007; 13:206–208.
Echocardiography
CASE REPORTS Section Editor: Brian D. Hoit, M.D.
Left Ventricular Rupture after Embolic Myocardial Infarction Due to Mitral Valve Endocarditis Thibault Caspar, M.D.,* Xavier Delabranche, M.D., Ph.D.,† Jean-Philippe Mazzucotelli, M.D., Ph.D.,‡ Hafida Samet, M.D.,* Olivier Morel, M.D., Ph.D.,* and Patrick Ohlmann, M.D., Ph.D.* *Department of Cardiology, University Hospital of Strasbourg, Strasbourg, France; †Intensive Care Unit, University Hospital of Strasbourg, Strasbourg, France; and ‡Cardiac Surgery, University Hospital of Strasbourg, Strasbourg, France
We report a very rare case of a 43-year-old patient with fatal left ventricular subepicardial aneurysm rupture complicating embolic myocardial infarction due to mitral valve infective endocarditis. (Echocardiography 2014;31:E104–E106) Key words: left ventricular rupture, subepicardial aneurysm, infective endocarditis, embolic myocardial infarction A 43-year-old man with a history of heroin addiction treated with buprenorphin was admitted to local hospital for fever and fatigue. Infective mitral valve endocarditis was diagnosed on transthoracic and transesophageal echocardiography (Philips, Amsterdam, The Netherlands) (Fig. 1) showing 2 vegetations on each mitral leaflet, with a perforation of the anterior mitral leaflet and moderate regurgitation. Blood cultures were positive for methicillin-sensitive Staphylococcus aureus. The patient was treated with intravenous antibiotics (oxacillin and gentamicin). Systemic emboli were found in the toes on clinical examination, and in brain, spleen, and kidneys on computed tomography (General Electric, Fairfield, CT, USA). Six days later, he suddenly experienced chest pain, with ST-segment elevation in V3–V4 leads. Coronary angiography (Philips) was emergently performed showing distal left anterior descending artery occlusion (Fig. 2). Other coronary arteries were normal. The patient was referred to our tertiary hospital for surgical treatment of mitral valve endocarditis. Mitral valve repair was performed on day 10 after initial diagnosis of infective endocarditis. The first postoperative days were uneventful with clinical improvement of the patient’s status. Two weeks after surgery, chest CT scan showed a left ventricular apical aneurysm, with a narrow neck and a thin wall made of necrotic myocarAddress for correspondence and reprint requests: Thibault ^ pitaux Universitaires de Strasbourg, Po ^ le Caspar, M.D., Ho ^pital Civil, 1, m edico-chirurgical cardio-vasculaire, Nouvel Ho ^ pital, F- 67091 Strasbourg Cedex, France. Place de l’Ho Fax: +33 (0) 369 551 879; E-mail: [email protected]
E104
dium, consistent with subepicardial aneurysm (Figs. 3 and 4) and complicating prior embolic myocardial infarction. A few days later, the patient experienced acute severe dyspnea with jugular venous distension and low blood pressure. Immediate echocardiography revealed a left ventricular apical wall rupture with pericardial effusion and right ventricular compression (Fig. 5). The patient was immediately transferred to cardiac surgery operating room with major hemodynamic instability and electromechanical dissociation. Cardiopulmonary resuscitation was performed for 15 minutes before extra corporeal circulation was initiated after open chest surgery. A voluminous ruptured subepicardial aneurysm was evidenced in the left ventricular apex with a large myocardial defect (30 mm). There was no evidence of endocardial or myocardial tissue
Figure 1. Transesophageal echocardiography: mid-esophageal mitral commissural view showing voluminous vegetation (arrow) on posterior mitral valve leaflet (P3 segment). LA = left atrium; LV = left ventricle; LAA = left atrial appendage.
Endocarditis, Embolic MI, Myocardial Rupture
Figure 2. Left coronary angiogram showing distal left anterior descending artery occlusion (arrow).
Figure 4. Computed tomography with 3D volume rendering reconstruction showing left ventricle apical aneurysm (arrow). LV = left ventricle; RV = right ventricle; AO = aorta; PA = pulmonary artery.
Figure 3. Chest computed tomography showing the four heart chambers and a left ventricular subepicardial apical aneurysm (arrow) with a diameter of 44 mm and a thin myocardial layer. LA = left atrium; LV = left ventricle; RA = right atrium; RV = right ventricle.
infection, and no pus was found in the pericardial cavity. Hemopericardium was evacuated, and surgical cardiomyoplasty using a pericardial patch was performed allowing temporary hemodynamic stabilization under epinephrine and norepinephrine infusion. However, later evolution was unfavorable despite extracorporeal life support and continuous renal replacement therapy and the patient died 2 weeks after surgery. Left ventricular rupture complicates approximately 2% of myocardial infarctions and accounts for 16% of hospital deaths after infarction.1 It is a diagnostic and therapeutic challenge, as it requires emergency surgical treatment. Echocardiography is of paramount importance to establish the diagnosis. The present case illustrates this rare complication with unfavorable
Figure 5. Transthoracic echocardiographic apical fourchamber view showing a large myocardial defect (arrow) in the left ventricular apical wall and a communication between the left ventricle and the pericardial cavity (ruptured aneurysm). LA = left atrium; LV = left ventricle; RA = right atrium; RV = right ventricle.
clinical course despite immediate surgery in a patient with embolic myocardial infarction due to mitral valve endocarditis. Myocardial infarction due to coronary artery septic embolization is very rare, with an estimated incidence of 0.3%, and is associated with a high risk of mortality.2 Moreover, subepicardial aneurysm is an uncommon complication of myocardial infarction. It is an abrupt interruption of the myocardium, with E105
Caspar, et al.
typically a narrow neck connecting the ventricular cavity with the aneurysmal pouch. The aneurysmal wall comprised epicardium with or without a thin myocardial layer and the risk of its rupture is high.3,4 Rupture of left ventricle in the clinical situation of an embolic myocardial infarction has only been reported sporadically in the literature,5 with to the best of our knowledge no previous publication of such echocardiography images. References 1. Shapira I, Isakov A, Burke M, et al: Cardiac rupture in patients with acute myocardial infarction. Chest 1987; 92:219–223.
E106
2. Fabri J Jr, Issa VS, Pomerantzeff PM, et al: Time-related distribution, risk factors and prognostic influence of embolism in patients with left-sided infective endocarditis. Int J Cardiol 2006;110:334–339. 3. Yang HS, Shah SB, Sweeney JP, et al: Subepicardial aneurysm evaluated by multiplane 2D and real-time 3D volumetric transesophageal echocardiography. Circ Cardiovasc Imaging 2008;1:171–172. 4. Roldan FJ, Vargas-Barron J, Aguirre-Espinosa M, et al: Subepicardial aneurysm: Echocardiographic evaluation and evolution. Echocardiography 2009;26:504–507. 5. Tayama E, Chihara S, Fukunaga S, et al: Embolic myocardial infarction and left ventricular rupture due to mitral valve endocarditis. Ann Thorac Cardiovasc Surg 2007; 13:206–208.
