Acute Left Ventricle Free-Wall Rupture Post Primary PCI: In Vivo Imaging

J INVASIVE CARDIOL 2022;34(3):E253-E254.

Key words: left ventricular rupture, primary PCI, STEMI

A 69-year-old male was referred to our cath lab for primary percutaneous coronary intervention (PCI) due to acute anterior ST-segment elevation myocardial infarction. The door to balloon time was about 8 hours. Left coronary angiography revealed acute occlusion of the proximal left anterior descending (LAD) artery (Figure 1 and Video 1). We immediately performed primary PCI throughout thrombus aspiration (Figure 2 and Video 2) followed by implantation of a 3 x 18 mm drug-eluting-stent (Figure 3 and Video 3). Control angiography showed no reflow (Figure 4 and Video 4). At the end of the percutaneous procedure, an abrupt clinical deterioration manifested with sudden hypotension. Transthoracic echocardiogram evidenced acute cardiac tamponade and we attempted emergency percutaneous under xiphoid pericardiocentesis. Failure to resolve cardiac tamponade and persistent hemorrhage obliged us to perform surgical subxiphoyd pericardial incision. However, the constant supply of blood from the pericardium and the development of cardiogenic shock state led us to suspect cardiac laceration. An emergency sternotomy was immediately performed.

Postpericardiotomy inspection showed a 3-cm left ventricular (LV) free-wall rupture (Figure 5 and Video 5) parallel to the mid LAD. A 4/0-prolene continuous suture reinforced with TachoSil and autologous pericardium was used to try to close the perforation on a beating heart. Nevertheless, the progression of the laceration on the LV anterolateral wall was soon followed by cardiac irreversible deterioration, leading to the patient’s death.

The incidence of LV free-wall rupture post acute myocardial infarction is <1%, but mortality is extremely high. This imaging series illustrates a heart team operating in vivo on a rare acute myocardial infarction mechanical complication, which occurred soon after primary PCI.

• Mortality in STEMI Patients With Cardiogenic Shock: Results From a Nationwide PCI Registry and Focus on Left Main PCI
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