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Heart, Lung and Circulation (2015) xx, 1–4 1443-9506/04/$36.00 http://dx.doi.org/10.1016/j.hlc.2014.12.167
CLINICAL SPOTLIGHT
LV Apical Rupture Complicating Acute Myocardial Infarction: The Role of CMR D.F. Waterhouse, T. Murphy, J. McCarthy, J. O’Neill, R. O’Hanlon Received 22 August 2014; received in revised form 9 December 2014; accepted 11 December 2014; online published-ahead-of-print xxx
Purpose
This case illustrates an acute myocardial infarction with occlusion of the left anterior descending coronary artery complicated by apical ventricular rupture and apical thrombus.
Procedures
An electrocardiogram, [3_TD$IF]transthoracic echocardiogram (TTE), coronary angiography and cardiac magnetic resonance imaging (CMR) guided optimal management of the patient.
Findings
Coronary angiography revealed multivessel disease with an ostial occlusion of the LAD. Echocardiography showed apical dilatation of the left ventricle with a large, echogenic mass at the apex. Contrast echocardiography confirmed the presence of a large apical thrombus, separated from the LV cavity by myocardium. A CMR showed a completed LAD infarct and a filling thrombus was noted in the aneurysmal apical region inferring a contained rupture of the LV apex.
Principle Conclusions
Accurate and definitive delineation of unusual cardiac anatomy is best provided by complementary multimodality cardiac imaging, echocardiography and CMR. TTE can miss LV thrombi, particularly when they are large, aneurysmal and apical in nature. CMR provides the cardiac surgeon the ability to visualise in 3D the functional and morphological abnormalities, helping guide necessary intervention. Optimal management of patients with ventricular rupture remains controversial both in terms of timing and choice of intervention.
Keywords
Cardiac Imaging techniques Myocardial infarction Electrocardiography Magnetic resonance imaging cine Echocardiography
Case A previously fit and well 57 year-old male with a history of type II diabetes mellitus, presented to the emergency department with a 10-hour history of central chest pain. His ECG was consistent with a completed anterior STEMI (Image 1) and troponin was elevated. Given ongoing chest pain, the patient proceeded to emergent coronary angiogram. This demonstrated complex multivessel disease with an ostial occlusion of the left anterior descending artery (LAD), which could not be opened. Left ventriculogram (LVgram) showed severe LV dysfunction with a significantly dyskinetic apex. Echocardiography on day 2 showed anterior thinning and akinesis and severe LV dysfunction. There was apical dilatation of the LV with a large, echogenic mass visualised at the LV apex. Contrast echocardiography was thus performed which
confirmed the presence of a large LV apical thrombus, separated from the LV cavity by myocardium (Image 2a). Given these findings, the patient was commenced on apixiban. To assess myocardial viability and guide a revascularisation strategy, as well as to further define the pathology in the LV apex, a cardiac MRI (CMR) was performed (Siemens Aera 1.5T). Images were analysed using CMR 42 software (Circle CVI, Calgary). The CMR demonstrated akinesis of the anterior and antero-septal walls from mid ventricle through to the apex. As expected the apex was thinned, akinetic and aneurysmal. Short Tau Inversion Recovery, STIR, images demonstrated increased signal intensity in the thinned akinetic anterior and septal walls from mid ventricle through to apex, strongly suggestive of an acute infarct pattern (Image 2B). A large filling defect was noted in the apex with a mobile nature consistent with a large mobile LV thrombus, which was confirmed on early gadolinium imaging. (Video 1) Late
© 2015 Published by Elsevier Inc on behalf of Australian and New Zealand Society of Cardiac and Thoracic Surgeons (ANZSCTS) and the Cardiac Society of Australia and New Zealand (CSANZ).
Please cite this article in press as: Waterhouse DF, et al. LV Apical Rupture Complicating Acute Myocardial Infarction: The Role of CMR. Heart, Lung and Circulation (2015), http://dx.doi.org/10.1016/j.hlc.2014.12.167
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Image 1 Electrocardiogram showing completed anterior ST elevation myocardial infarction with ST elevation in V3-V6 and limb leads III.
gadolinium enhancement (LGE) demonstrated transmural infarction in the anterior and septal walls from the basal LV to the apex consistent with a completed LAD infarct. Filling thrombus was noted with altered signal intensity of the LGE in the aneurysmal apical region suggesting a contained rupture of the LV apex. (Image 2C, 2D) These results confirmed the diagnosis of a contained LV apical rupture following myocardial infarction. Following detailed discussion of the treatment options with the patient and his family, a surgical approach was chosen. (Image 2E, 2F)
Discussion Myocardial rupture is the most feared, and often fatal, complication of acute MI. It is found in less than 1% of surviving patients with an acute MI, accounting for up to 20% of their mortality [1]. Presentation can be dramatic with tamponade and shock, or may be subacute with arrhythmia, prolonged or recurrent chest pain, and heart failure [2]. As with our patient, those with first presentation of an infarction, particularly involving the LAD coronary artery, are at increased risk of myocardial rupture [3]. It is thought that the infarcted myocardium wall is weakened by activation of metalloproteinases, which degrade the myocardial matrix and predispose the myocardial wall to rupture. Accurate and definitive delineation of the rupture is best provided by complementary multimodality cardiac imaging
including ventriculography, TTE and CMR. Although commonly used, TTE can miss LV thrombi, particularly when they[4_TD$IF] are large, aneurysmal and apical in nature [4]. This case illustrates, CMR with its high spatial resolution, is crucial for the accurate delineation of the anatomy, location, and size of the lesion prior to surgical correction. Furthermore, CMR provides the cardiac surgeon the ability to visualise in 3D, the functional and morphological abnormalities, helping guide necessary intervention. Optimal management of patients with ventricular rupture remains controversial both in terms of timing and choice of intervention. Retrospective data has demonstrated a decrease in operative mortality rates in patients with a longer (>6 weeks) interval between myocardial infarction and surgical repair [5]. However, this longer time interval introduces an inherent survival bias by selecting the more stable patients. The choice of intervention varies with the clinical presentation. For patients presenting acutely in cardiogenic shock, emergent treatment is necessary. This may be in the form of immediate surgical repair or temporary mechanical circulatory support followed by definitive repair. Although percutaneous repair has been reported in older patients with smaller defects, no studies have directly compared both percutaneous and surgical approaches [6]. Elective surgery is preferred for patients who are haemodynamically stable. In summary, this case illustrates LAD infarction complicated by apical ventricular rupture and apical thrombus.
Please cite this article in press as: Waterhouse DF, et al. LV Apical Rupture Complicating Acute Myocardial Infarction: The Role of CMR. Heart, Lung and Circulation (2015), http://dx.doi.org/10.1016/j.hlc.2014.12.167
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Image 2 A: Contrast Trans-thoracic Echocardiography showing a large apical thrombus, separated from LV cavity by the myocardium. B: 4C - STIR imaging showing increased signal intensity in the thinned anterior and septal walls from mid ventricle through to apex, strongly suggestive of an acute infarct pattern also noted apical thrombus, separated from LV cavity by myocardium. C: 2C Late gadolinium imaging showing apical thrombus and thinned anterior wall. D: 3C Late gadolinium Imaging showing increased signal intensity in the antero-septal wall consistent with infarction and noted apical thrombus. E: Intra-operative image of the ventricular apical aneurysm. F: Evacuation of apical thrombus and repair of ventricular apical aneurysm.
Please cite this article in press as: Waterhouse DF, et al. LV Apical Rupture Complicating Acute Myocardial Infarction: The Role of CMR. Heart, Lung and Circulation (2015), http://dx.doi.org/10.1016/j.hlc.2014.12.167
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Appendix A. Supplementary data Supplementary data associated with this article can be found, in the online version, at http://dx.doi.org/10.1016/j.hlc. 2014.12.167.
References [1] Becker RC, Gore JM, Lambrew C, Weaver WD, Rubison RM, French WJ, et al. A composite view of cardiac rupture in the United States National Registry of Myocardial Infarction. J Am Coll Cardiol 1996;[2_TD$IF] 27:1321–6.
[2] Birnbaum Y, Chamoun AJ, Anzuini A, Lick SD, Ahmad M, Uretsky BF. Ventricular free wall rupture following acute myocardial infarction. Coron Artery Dis 2003;14:463–70. [3] Skehan JD, Carey C, Norrell MS, de Belder M, Balcon R, Mills PG. Patterns of coronary artery disease in post-infarction ventricular septal rupture. Br Heart J 1989;62(4):268–72. [4] Mollet NR, Dymarkowski S, Volders W, Wathiong J, Herbots L, Rademakers FE, et al. Visualization of ventricular thrombi with contrastenhanced magnetic resonance imaging in patients with ischemic heart disease. Circulation 2002;106:2873–6. [5] Daggett WM, Guyton RA, Mundth ED, Buckley MJ, McEnany MT, Gold HK, et al. Surgery for post-myocardial infarct ventricular septal defect. Ann Surg 1977;186(3):260–71. [6] Maltais S, Ibrahim R, Basmadjian AJ, Carrier M, Bouchard D, Cartier R, et al. Post infarction ventricular septal defects: towards a new treatment algorithm? Ann Thorac Surg 2009;30:81–8.
Please cite this article in press as: Waterhouse DF, et al. LV Apical Rupture Complicating Acute Myocardial Infarction: The Role of CMR. Heart, Lung and Circulation (2015), http://dx.doi.org/10.1016/j.hlc.2014.12.167
Heart, Lung and Circulation (2015) xx, 1–4 1443-9506/04/$36.00 http://dx.doi.org/10.1016/j.hlc.2014.12.167
CLINICAL SPOTLIGHT
LV Apical Rupture Complicating Acute Myocardial Infarction: The Role of CMR D.F. Waterhouse, T. Murphy, J. McCarthy, J. O’Neill, R. O’Hanlon Received 22 August 2014; received in revised form 9 December 2014; accepted 11 December 2014; online published-ahead-of-print xxx
Purpose
This case illustrates an acute myocardial infarction with occlusion of the left anterior descending coronary artery complicated by apical ventricular rupture and apical thrombus.
Procedures
An electrocardiogram, [3_TD$IF]transthoracic echocardiogram (TTE), coronary angiography and cardiac magnetic resonance imaging (CMR) guided optimal management of the patient.
Findings
Coronary angiography revealed multivessel disease with an ostial occlusion of the LAD. Echocardiography showed apical dilatation of the left ventricle with a large, echogenic mass at the apex. Contrast echocardiography confirmed the presence of a large apical thrombus, separated from the LV cavity by myocardium. A CMR showed a completed LAD infarct and a filling thrombus was noted in the aneurysmal apical region inferring a contained rupture of the LV apex.
Principle Conclusions
Accurate and definitive delineation of unusual cardiac anatomy is best provided by complementary multimodality cardiac imaging, echocardiography and CMR. TTE can miss LV thrombi, particularly when they are large, aneurysmal and apical in nature. CMR provides the cardiac surgeon the ability to visualise in 3D the functional and morphological abnormalities, helping guide necessary intervention. Optimal management of patients with ventricular rupture remains controversial both in terms of timing and choice of intervention.
Keywords
Cardiac Imaging techniques Myocardial infarction Electrocardiography Magnetic resonance imaging cine Echocardiography
Case A previously fit and well 57 year-old male with a history of type II diabetes mellitus, presented to the emergency department with a 10-hour history of central chest pain. His ECG was consistent with a completed anterior STEMI (Image 1) and troponin was elevated. Given ongoing chest pain, the patient proceeded to emergent coronary angiogram. This demonstrated complex multivessel disease with an ostial occlusion of the left anterior descending artery (LAD), which could not be opened. Left ventriculogram (LVgram) showed severe LV dysfunction with a significantly dyskinetic apex. Echocardiography on day 2 showed anterior thinning and akinesis and severe LV dysfunction. There was apical dilatation of the LV with a large, echogenic mass visualised at the LV apex. Contrast echocardiography was thus performed which
confirmed the presence of a large LV apical thrombus, separated from the LV cavity by myocardium (Image 2a). Given these findings, the patient was commenced on apixiban. To assess myocardial viability and guide a revascularisation strategy, as well as to further define the pathology in the LV apex, a cardiac MRI (CMR) was performed (Siemens Aera 1.5T). Images were analysed using CMR 42 software (Circle CVI, Calgary). The CMR demonstrated akinesis of the anterior and antero-septal walls from mid ventricle through to the apex. As expected the apex was thinned, akinetic and aneurysmal. Short Tau Inversion Recovery, STIR, images demonstrated increased signal intensity in the thinned akinetic anterior and septal walls from mid ventricle through to apex, strongly suggestive of an acute infarct pattern (Image 2B). A large filling defect was noted in the apex with a mobile nature consistent with a large mobile LV thrombus, which was confirmed on early gadolinium imaging. (Video 1) Late
© 2015 Published by Elsevier Inc on behalf of Australian and New Zealand Society of Cardiac and Thoracic Surgeons (ANZSCTS) and the Cardiac Society of Australia and New Zealand (CSANZ).
Please cite this article in press as: Waterhouse DF, et al. LV Apical Rupture Complicating Acute Myocardial Infarction: The Role of CMR. Heart, Lung and Circulation (2015), http://dx.doi.org/10.1016/j.hlc.2014.12.167
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Image 1 Electrocardiogram showing completed anterior ST elevation myocardial infarction with ST elevation in V3-V6 and limb leads III.
gadolinium enhancement (LGE) demonstrated transmural infarction in the anterior and septal walls from the basal LV to the apex consistent with a completed LAD infarct. Filling thrombus was noted with altered signal intensity of the LGE in the aneurysmal apical region suggesting a contained rupture of the LV apex. (Image 2C, 2D) These results confirmed the diagnosis of a contained LV apical rupture following myocardial infarction. Following detailed discussion of the treatment options with the patient and his family, a surgical approach was chosen. (Image 2E, 2F)
Discussion Myocardial rupture is the most feared, and often fatal, complication of acute MI. It is found in less than 1% of surviving patients with an acute MI, accounting for up to 20% of their mortality [1]. Presentation can be dramatic with tamponade and shock, or may be subacute with arrhythmia, prolonged or recurrent chest pain, and heart failure [2]. As with our patient, those with first presentation of an infarction, particularly involving the LAD coronary artery, are at increased risk of myocardial rupture [3]. It is thought that the infarcted myocardium wall is weakened by activation of metalloproteinases, which degrade the myocardial matrix and predispose the myocardial wall to rupture. Accurate and definitive delineation of the rupture is best provided by complementary multimodality cardiac imaging
including ventriculography, TTE and CMR. Although commonly used, TTE can miss LV thrombi, particularly when they[4_TD$IF] are large, aneurysmal and apical in nature [4]. This case illustrates, CMR with its high spatial resolution, is crucial for the accurate delineation of the anatomy, location, and size of the lesion prior to surgical correction. Furthermore, CMR provides the cardiac surgeon the ability to visualise in 3D, the functional and morphological abnormalities, helping guide necessary intervention. Optimal management of patients with ventricular rupture remains controversial both in terms of timing and choice of intervention. Retrospective data has demonstrated a decrease in operative mortality rates in patients with a longer (>6 weeks) interval between myocardial infarction and surgical repair [5]. However, this longer time interval introduces an inherent survival bias by selecting the more stable patients. The choice of intervention varies with the clinical presentation. For patients presenting acutely in cardiogenic shock, emergent treatment is necessary. This may be in the form of immediate surgical repair or temporary mechanical circulatory support followed by definitive repair. Although percutaneous repair has been reported in older patients with smaller defects, no studies have directly compared both percutaneous and surgical approaches [6]. Elective surgery is preferred for patients who are haemodynamically stable. In summary, this case illustrates LAD infarction complicated by apical ventricular rupture and apical thrombus.
Please cite this article in press as: Waterhouse DF, et al. LV Apical Rupture Complicating Acute Myocardial Infarction: The Role of CMR. Heart, Lung and Circulation (2015), http://dx.doi.org/10.1016/j.hlc.2014.12.167
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Image 2 A: Contrast Trans-thoracic Echocardiography showing a large apical thrombus, separated from LV cavity by the myocardium. B: 4C - STIR imaging showing increased signal intensity in the thinned anterior and septal walls from mid ventricle through to apex, strongly suggestive of an acute infarct pattern also noted apical thrombus, separated from LV cavity by myocardium. C: 2C Late gadolinium imaging showing apical thrombus and thinned anterior wall. D: 3C Late gadolinium Imaging showing increased signal intensity in the antero-septal wall consistent with infarction and noted apical thrombus. E: Intra-operative image of the ventricular apical aneurysm. F: Evacuation of apical thrombus and repair of ventricular apical aneurysm.
Please cite this article in press as: Waterhouse DF, et al. LV Apical Rupture Complicating Acute Myocardial Infarction: The Role of CMR. Heart, Lung and Circulation (2015), http://dx.doi.org/10.1016/j.hlc.2014.12.167
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Appendix A. Supplementary data Supplementary data associated with this article can be found, in the online version, at http://dx.doi.org/10.1016/j.hlc. 2014.12.167.
References [1] Becker RC, Gore JM, Lambrew C, Weaver WD, Rubison RM, French WJ, et al. A composite view of cardiac rupture in the United States National Registry of Myocardial Infarction. J Am Coll Cardiol 1996;[2_TD$IF] 27:1321–6.
[2] Birnbaum Y, Chamoun AJ, Anzuini A, Lick SD, Ahmad M, Uretsky BF. Ventricular free wall rupture following acute myocardial infarction. Coron Artery Dis 2003;14:463–70. [3] Skehan JD, Carey C, Norrell MS, de Belder M, Balcon R, Mills PG. Patterns of coronary artery disease in post-infarction ventricular septal rupture. Br Heart J 1989;62(4):268–72. [4] Mollet NR, Dymarkowski S, Volders W, Wathiong J, Herbots L, Rademakers FE, et al. Visualization of ventricular thrombi with contrastenhanced magnetic resonance imaging in patients with ischemic heart disease. Circulation 2002;106:2873–6. [5] Daggett WM, Guyton RA, Mundth ED, Buckley MJ, McEnany MT, Gold HK, et al. Surgery for post-myocardial infarct ventricular septal defect. Ann Surg 1977;186(3):260–71. [6] Maltais S, Ibrahim R, Basmadjian AJ, Carrier M, Bouchard D, Cartier R, et al. Post infarction ventricular septal defects: towards a new treatment algorithm? Ann Thorac Surg 2009;30:81–8.
Please cite this article in press as: Waterhouse DF, et al. LV Apical Rupture Complicating Acute Myocardial Infarction: The Role of CMR. Heart, Lung and Circulation (2015), http://dx.doi.org/10.1016/j.hlc.2014.12.167
