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Intramyocardial Dissection following Postinfarction Ventricular Wall Rupture Contained by Surrounding Postoperative Adhesions.

Ercan A, Gurbuz O, Kumtepe G, Ozkan H, Karal IH, Velioglu Y, Ener S - Case Rep Surg (2015)

Bottom Line: Intraventricular patch repair technic with autologous pericardial patch was used to exclude the ruptured area.Following the warming period, despite adequate hemostasis, hemorrhage around suture lines progressively increased, leading to the patient's death.Conclusion.

View Article: PubMed Central - PubMed

Affiliation: Department of Cardiovascular Surgery, Balıkesir University Medical Faculty, Bigadiç, 10145 Balıkesir, Turkey.

ABSTRACT
Introduction. Dissection of the myocardium is a rare form of cardiac rupture, caused by a hemorrhagic dissection among the spiral myocardial fibers, its diagnosis is rarely established before the operation or death, and extremely few cases have been reported in the literature and none of these cases seem to have a history of previous cardiac surgery which makes our report unique. Case Presentation. A 61-year-old female patient was admitted into the emergency room with complaints of progressive chest pain for 2 days. She had a history of second time prosthetic aortic valve replacement and was under anticoagulation therapy. She was diagnosed with an acute inferoposterior myocardial infarction and underwent emergency coronary angiography revealing spontaneous recanalization of the right coronary artery. During the follow-up, she developed cardiogenic shock and a new occurring systolic ejection murmur. Transthoracic echocardiography showed a left ventricular free wall rupture; then, she was taken in for emergency surgery. During the operation, a rupture zone and a wide intramyocardial dissecting area were detected. Intraventricular patch repair technic with autologous pericardial patch was used to exclude the ruptured area. Following the warming period, despite adequate hemostasis, hemorrhage around suture lines progressively increased, leading to the patient's death. Conclusion. Pericardial adhesions might contain left ventricular rupture leading to intramyocardial dissection.

No MeSH data available.


Related in: MedlinePlus

Modified apical four-chambered view in transthoracic echocardiography showing the defect (b) (marked by white arrow) and color jet (a) through it. LV: left ventricle, RV: right ventricle, RA: right atrium, and IMD: intramyocardial dissection area.
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fig1: Modified apical four-chambered view in transthoracic echocardiography showing the defect (b) (marked by white arrow) and color jet (a) through it. LV: left ventricle, RV: right ventricle, RA: right atrium, and IMD: intramyocardial dissection area.

Mentions: A 61-year-old Caucasian female patient was admitted into the emergency room with complaints of progressive chest pain for 2 days, becoming continuous for the past 3-4 hours. The patient had a history of second time prosthetic aortic valve replacement and was under anticoagulation therapy. On physical examination, she presented a moderate general status and was hemodynamically stable. Electrocardiography (ECG) on admission showed sinus rhythm, ST segment elevation in leads D2, D3, and aVF, and ST segment depression in leads V1–3. Laboratory examinations revealed aninternational normalized ratio (INR) of 3.6 (normal, 0.8–1.2), creatine kinase muscle-brain fraction (CK-MB) level of 103 U/L (normal, 0–25 U/L), and a cardiac troponin I (cTnI) level of 6 ng/dL (normal, <0.01 ng/mL). She was diagnosed with an acute inferoposterior myocardial infarction (MI) and underwent emergency coronary angiography revealing spontaneous recanalization of the right coronary artery and also no significant stenosis in the left coronary artery. Medical treatment decision was taken and the patient transferred to the coronary care unit. Twenty-four hours after admission, she developed cardiogenic shock requiring intra-aortic balloonpump (IABP) placement. Physical examination revealed a new occurring systolic ejection murmur. Transthoracic echocardiography showed a left ventricular septum rupture (Figure 1); then, she was takenin for emergency surgery. During the operation, following adhesion's removal, a 2 × 3 cm2 rupture zone in the middle and the apical segment of posterolateral wall and a wide intramyocardial dissecting area around it extending into basal segments were detected (Figure 2) and the ventricular septum was intact. Intraventricular patch repair technic with autologous pericardial patch about 4 × 4 cm was used to exclude the ruptured area. A fibrin sealant (Tisseel, Baxter, USA) was applied between dissecting ventricular wall layers. Then, two strips of Teflon felt were applied at the borders of the ruptured area and were joined together by horizontal mattress sutures excluding the necrotic walls. Following the warming period, despite adequate hemostasis, hemorrhage around suture lines progressively increased, leading to the patient's death.


Intramyocardial Dissection following Postinfarction Ventricular Wall Rupture Contained by Surrounding Postoperative Adhesions.

Ercan A, Gurbuz O, Kumtepe G, Ozkan H, Karal IH, Velioglu Y, Ener S - Case Rep Surg (2015)

Modified apical four-chambered view in transthoracic echocardiography showing the defect (b) (marked by white arrow) and color jet (a) through it. LV: left ventricle, RV: right ventricle, RA: right atrium, and IMD: intramyocardial dissection area.
© Copyright Policy - open-access
Related In: Results  -  Collection

Show All Figures
getmorefigures.php?uid=PMC4383428&req=5

fig1: Modified apical four-chambered view in transthoracic echocardiography showing the defect (b) (marked by white arrow) and color jet (a) through it. LV: left ventricle, RV: right ventricle, RA: right atrium, and IMD: intramyocardial dissection area.
Mentions: A 61-year-old Caucasian female patient was admitted into the emergency room with complaints of progressive chest pain for 2 days, becoming continuous for the past 3-4 hours. The patient had a history of second time prosthetic aortic valve replacement and was under anticoagulation therapy. On physical examination, she presented a moderate general status and was hemodynamically stable. Electrocardiography (ECG) on admission showed sinus rhythm, ST segment elevation in leads D2, D3, and aVF, and ST segment depression in leads V1–3. Laboratory examinations revealed aninternational normalized ratio (INR) of 3.6 (normal, 0.8–1.2), creatine kinase muscle-brain fraction (CK-MB) level of 103 U/L (normal, 0–25 U/L), and a cardiac troponin I (cTnI) level of 6 ng/dL (normal, <0.01 ng/mL). She was diagnosed with an acute inferoposterior myocardial infarction (MI) and underwent emergency coronary angiography revealing spontaneous recanalization of the right coronary artery and also no significant stenosis in the left coronary artery. Medical treatment decision was taken and the patient transferred to the coronary care unit. Twenty-four hours after admission, she developed cardiogenic shock requiring intra-aortic balloonpump (IABP) placement. Physical examination revealed a new occurring systolic ejection murmur. Transthoracic echocardiography showed a left ventricular septum rupture (Figure 1); then, she was takenin for emergency surgery. During the operation, following adhesion's removal, a 2 × 3 cm2 rupture zone in the middle and the apical segment of posterolateral wall and a wide intramyocardial dissecting area around it extending into basal segments were detected (Figure 2) and the ventricular septum was intact. Intraventricular patch repair technic with autologous pericardial patch about 4 × 4 cm was used to exclude the ruptured area. A fibrin sealant (Tisseel, Baxter, USA) was applied between dissecting ventricular wall layers. Then, two strips of Teflon felt were applied at the borders of the ruptured area and were joined together by horizontal mattress sutures excluding the necrotic walls. Following the warming period, despite adequate hemostasis, hemorrhage around suture lines progressively increased, leading to the patient's death.

Bottom Line: Intraventricular patch repair technic with autologous pericardial patch was used to exclude the ruptured area.Following the warming period, despite adequate hemostasis, hemorrhage around suture lines progressively increased, leading to the patient's death.Conclusion.

View Article: PubMed Central - PubMed

Affiliation: Department of Cardiovascular Surgery, Balıkesir University Medical Faculty, Bigadiç, 10145 Balıkesir, Turkey.

ABSTRACT
Introduction. Dissection of the myocardium is a rare form of cardiac rupture, caused by a hemorrhagic dissection among the spiral myocardial fibers, its diagnosis is rarely established before the operation or death, and extremely few cases have been reported in the literature and none of these cases seem to have a history of previous cardiac surgery which makes our report unique. Case Presentation. A 61-year-old female patient was admitted into the emergency room with complaints of progressive chest pain for 2 days. She had a history of second time prosthetic aortic valve replacement and was under anticoagulation therapy. She was diagnosed with an acute inferoposterior myocardial infarction and underwent emergency coronary angiography revealing spontaneous recanalization of the right coronary artery. During the follow-up, she developed cardiogenic shock and a new occurring systolic ejection murmur. Transthoracic echocardiography showed a left ventricular free wall rupture; then, she was taken in for emergency surgery. During the operation, a rupture zone and a wide intramyocardial dissecting area were detected. Intraventricular patch repair technic with autologous pericardial patch was used to exclude the ruptured area. Following the warming period, despite adequate hemostasis, hemorrhage around suture lines progressively increased, leading to the patient's death. Conclusion. Pericardial adhesions might contain left ventricular rupture leading to intramyocardial dissection.

No MeSH data available.


Related in: MedlinePlus