Intra-myocardial dissecting hematoma: late complication of cocaine-induced myocardial infarction

ABSTRACT

Intra-myocardial dissecting hematoma (IDH) is a rare and unusual form of myocardial rupture that can be secondary to complicate acute myocardail infarction (MI). It is usually caused by a hemorrhagic dissection between the layers of myocardial fibers that can occur during the acute injury or the remodeling process. This case demonstrates a patient with a history of cocaine-induced ischemic cardiomyopathy complicated with an extensive IDH. Case description A 38-year-old man with a past medical history of hypertension, heart failure with reduced ejection fraction (HFrEF), and cocaine abuse disorder, presents to the emergency department complaining of worsening shortness of breath. Six months before the current hospitalization, the patient had been diagnosed with acute myocardial infarction, left heart Cath showed a severe three-vessel coronary artery disease, but it was non-suitable for revascularization. The transthoracic echocardiogram (TTE) showed significant left ventricular dysfunction with an ejection fraction of 28% and a thrombus in the left ventricle. Four days before the current admission, the patient started complaining of worsening exertional dyspnea, orthopnea, and peripheral edema. His vital signs were BP 90 x 62mmhg, HR 104 bpm, SatO2 90% and afebrile. His physical examination revealed an increased jugular venous pressure, significant symmetric peripheral edema (3+/4), and cold extremities. Cardiac auscultation revealed a regular rhythm, S3, without murmrs. A pulmonary exam revealed bilateral crackles on the inferior 1/3 of the lungs. EKG showed sinus tachycardia and prior inferior necrosis. Renal function was normal, but lactate acid was elevated (2.6mg/dL). The patient was started with noninvasive ventilation, along with IV diuretic therapy, vasopressor, and inotropic support (dobutamine). A TTE was performed which showed an intra-myocardial dissecting hematoma in the inferior left ventricle (LV) wall, along with a large thrombus in the LV chamber and severe biventricular dysfunction (ejection fraction was 23%). Our patient responded well to the medical treatment. Due to his severely reduced left ventricular ejection fraction (LVEF), the IDH was managed conservatively. He was discharged on standard medication for HFrEF and oral anticoagulation. Discussion this case demonstrates IDH as a late complication following a cocaine-induced MI. Two-dimensional echocardiography is useful in the diagnosis of IDH as well as in ruling out potential differential diagnoses. Conservative treatment is a viable option, especially for those patients not suitable for cardiac revascularization with severely reduced left ventricular ejection.