Post myocardial infarction ventricular septal defect causing left ventricular intramyocardial dissecting hematoma: a ver
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IMAGES IN CARDIOVASCULAR ULTRASOUND
Post myocardial infarction ventricular septal defect causing left ventricular intramyocardial dissecting hematoma: a very rare complication Surender Deora • Sunil N. Gurmukhani Sanjay Shah • Tejas Patel
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Received: 3 February 2013 / Revised: 25 February 2013 / Accepted: 7 March 2013 Ó Japanese Society of Echocardiography 2013
A 73-year-old male smoker with a past history of type II diabetes mellitus and dyslipidemia was admitted with chest pain and dyspnea of 7-h duration. He was diagnosed as having anterior wall myocardial infarction and was thrombolyzed with streptokinase, as the patient and his relatives refused coronary angiography and percutaneous coronary intervention if needed. Two-dimensional transthoracic echocardiography (TTE) revealed severe left ventricular systolic dysfunction [ejection fraction (EF) *25 %] and a pulsatile cavity surrounded by a thin endomyocardial layer with wavy movement and no pericardial effusion (Fig. 1a; Supplementary Material Video 1). With slight tilting of the transducer, a small ventricular septal defect was seen communicating with the dissected cavity in the
Electronic supplementary material The online version of this article (doi:10.1007/s12574-013-0173-1) contains supplementary material, which is available to authorized users. S. Deora (&) S. N. Gurmukhani S. Shah T. Patel Department of Cardiovascular Sciences, Sheth V.S. General Hospital, Smt. N.H.L. Municipal Medical College, Gujarat University, Ahmedabad, Gujarat 380006, India e-mail: [email protected] S. N. Gurmukhani e-mail: [email protected] S. Shah e-mail: [email protected] T. Patel e-mail: [email protected]
infarcted left ventricular myocardium (Fig. 1b, arrow; Supplementary Material Videos 2 and 3). Serial TTE revealed changes in the acoustic character of the hematoma from unorganized hematoma to partially organized at the time of discharge and nearly organized and resolving hematoma at 1-month follow-up (Fig. 2). The patient was hemodynamically stable, so was managed conservatively. An intramyocardial dissecting hematoma (IDH) is a rare complication following acute ST elevation myocardial infarction (STEMI). The actual incidence of IDH is not known, as only isolated case reports exist in the literature, but in an autopsy series of 106 patients of cardiac rupture, it was present in 21 % of cases [1]. It is caused by hemorrhagic dissection among the spiral myocardial fibers due to either the rupture of intramyocardial vessels or decreased tensile strength of the infarcted myocardium, as in our case, or acute increase of coronary capillary pressure [2, 3]. The outer wall of a neocavity is formed with pericardium and myocardium, while the inner wall is formed by a thin layer of myocardium and endocardium. It may be either contained and spontaneously resolve as in our case or may expand and rupture into adjacent structures. It has also been reported after chest trauma, cardiac surgery, inflammation, and endocarditis [4]. Persistent ST elevation more th
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