Lateral left ventricular wall rupture following acute myocardial infarction: pathophysiological interpretation by multimodality imaging approach.

Lateral left ventricular wall rupture (LVWR) is a rare complication following acute myocardial infarction (AMI) less than 1%. After cardiogenic shock, LVWR constitutes the most common cause of in-hospital death in AMI patients. Around 40% of all LVWR occurred during the first 24 hours and 85% within the first week. In the present case, 76 hours following the intervention, LVWR was observed likely due to a small infarction at the lateral left ventricular wall possibly due to the marginal lesion. Our patient refused surgery and was followed clinically. Eighteen months later, real time three-dimensional echocardiography showed a pseudoaneurysm.

[Ventricular pseudoaneurysm. Clinical and echocardiographic evolution]. / Pseudoaneurisma ventricular. Evolución clínica y ecocardiogiráfica.

The case of a patient with cardiac rupture following a myocardial infarction is presented. The rupture led to the formation of a ventricular pseudoaneurysm that was occupied by a thrombus that sealed the breakthrough point. The patient has survived without surgical treatment during the last 5 years.

Pseudoaneurisma ventricular. Evolución clínica y ecocardiográfica / Ventricular pseudoaneurysm. Clinical and echocardiographic evolution

Presentamos el caso de un paciente con una ruptura cardíaca secundaria a un infarto miocárdico al nivel del ápex del ventrículo izquierdo. La complicación mecánica condicionó la formación de un pseudoaneurisma que fue ocupado por un trombo que selló el punto de ruptura. El paciente sobrevive sin tratamiento quirúrgico tras 5 años de seguimiento.

The case of a patient with cardiac rupture following a myocardial infarction is presented. The rupture led to the formation of a ventricular pseudoaneurysm that was occupied by a thrombus that sealed the breakthrough point. The patient has survived without surgical treatment during the last 5 years. (Arch Cardiol Mex 2005; 75: 182-183).

Complicações mecânicas do infarto agudo do miocárdio com supradesnivelamento do segmento ST / Mechanical complications of acute ST-segment elevation myocardial infarction

Neste artigo são discutidas as principais complicações mecânicas que podem surgir na evolução pós-infarto agudo do miocárdio, incluindo insuficiência mitral isquêmica, comunicação interventricular, rotura da parede livre do ventrículo e aneurisma de ventrículo esquerdo.

Cirugía coronaria en el Hospital Dr. Gustavo Fricke; 20 años de evolución / Coronary surgery at Dr. Gustavo Fricke Hospital; twenty years of evolution

La cirugía de revascularización coronaria ha tenido un desarrollo muy significativo en todo el mundo desde que se describió por primera vez la técnica hace más de treinta años. En el Hospital Dr. Gustavo Fricke de Viña del Mar, pronto se celebrarán 20 años de la primera cirugía coronaria con circulación extracorpórea y hemos participado de la evolución de las técnicas quirúrgicas y del progreso tecnológico que han hecho de esta cirugía un tratamiento eficaz y seguro del paciente con lesiones coronarias significativas.A la fecha, de las 4.457 cirugías cardíacas mayores realizadas desde el año 1983, 2.687 corresponden a cirugía de revascularización coronaria. Se han empleado diversas técnicas quirúrgicas y se ha observado una morbilidad y mortalidad comparable a la descrita en la literatura mundial. Se describen algunas indicaciones, como también algunas consideraciones técnicas, las complicaciones más importantes y algunas líneas de desarrollo a futuro

Pseudo-aneurisma de ventrículo esquerdo por rotura cardíaca após infarto agudo do miocárdio: tratamento cirúrgico / Pseudoaneurysm of the left ventricle due to postinfarction ventricular rupture: surgical treatment

O pseudo-aneurisma de ventrículo esquerdo após infarto agudo do miocárdio é entidade rara. Quando diagnosticado, deverá ser operado logo que possível, devido ao risco aumentado de rotura de sua parede. No período de novembro de 1992 a junho de 1995, foram encaminhados ao nosso Serviço 3 pacientes com suspeita clínica de pseudo-aneurisma de ventrículo esquerdo (VE), com sinais clínicos, radiológicos, ecocardiográficos e angiográficos característicos da lesäo. O objetivo do trabalho é discutir o diagnóstico, a indicaçäo cirúrgica, as técnicas e táticas empregadas, as complicaçöes e os resultados cirúrgicos. Todos os pacientes foram submetidos ao ecodopplercardiograma transtorácico, que foi suficiente para o diagnóstico. Após propedêutica adequada, com realizaçäo de angiografia e ventriculografia, os pacientes foram submetidos à correçäo utilizaçäo de pericárdio bovino. Um dos pacientes apresentava comunicaçäo interventricular (CIV), que foi corrigida no mesmo ato cirúrgico. Os pacientes receberam alta em bom estado geral, com controle ecocardiográfico evidenciando a correçäo do pseudo-aneurisma.

[Papillary muscle rupture in myocardial infarction]. / Rotura de músculo papilar en el infarto miocárdico.

We report nine patients with acute mitral regurgitation secondary to post-infarction papillary rupture operated between 1980 and 1992. Seven cases had posterior papillary muscle rupture. All patients were in critical conditions with pulmonary edema at the moment of surgery. In eight cases, mitral valve replacement was performed (4 with mechanical prostheses) and in one, the valve was repaired with papillary muscle reimplantation. Six cases were also subjected to myocardial revascularization with sapheneous vein grafts. Two patients (22%) died during the postoperative period and 4 had postoperative complications. The seven survivors have been followed during 6 to 115 month. Of theses, one died six month after surgery due to congestive heart failure, three are in functional class I and the rest in functional class II. It is concluded that, although mitral valve replacement for papillary muscle rupture has a high operative mortality and morbidity, long term results are satisfactory.

[Diagnosis of papillary muscle rupture in acute myocardial infarction by transesophageal Doppler echocardiography]. / Diagnóstico da rotura do músculo papilar no infarto agudo do miocárdio através do ecodopplercardiograma transesofágico.

Three patients, two females, ages ranging from 62 to 78 years were studied, evolving with hypotension, acute pulmonary edema and cardiogenic shock. One had anterior myocardial infarction, and in two, infero-posterior. Due to severe hemodynamic instability and necessity of vasoactive drug therapy to maintain adequate arterial pressure, coronary angiography was performed in two, showing total occlusion of the circumflex artery and severe mitral regurgitation. In one case, angioplasty on the circumflex artery was successfully achieved. No hemodynamic improvement was observed, however. Doppler echocardiography depicted mild to moderate mitral regurgitation in the three cases. Transesophageal echo confirmed the clinical suspicion of papillary muscle rupture: total rupture of antero-lateral papillary muscle in one patient, as well as total and partial rupture of the postero-medial papillary muscle in the other two patients. Two patients were submitted to mitral valve replacement, and the surgical findings confirmed the transesophageal echo conclusions. One of them died in the immediate pos-operative period, whereas the other was discharged from the hospital and is doing well. The third patient died before operation. Differential diagnosis of acute mitral regurgitation due to papillary muscle dysfunction or rupture was not possible by left ventriculography or by transthoracic echo. Transesophageal echo was the only exam to clearly confirm papillary muscle rupture, as should be done promptly after clinical suspicion of this severe condition arises.

Diagnóstico da rotura do músculo papilar no infarto agudo do miocárdio através do ecodopplercardiograma transesofágico / Papillary Muscle Rupture Assessment Due To Acute Myocardial Infarction by Transesophagecel Echocardiography

Three patients, two females, ages ranging from 62 to 78 years were studied, evolving with hypotension, acute pulmonary edema and cardiogenic shock. One had anterior myocardial infarction, and in two, infero-posterior. Due to severe hemodynamic instability and necessity of vasoactive drug therapy to maintain adequate arterial pressure, coronary angiography was performed in two, showing total occlusion of the circumflex artery and severe mitral regurgitation. In one case, angioplasty on the circumflex artery was successfully achieved. No hemodynamic improvement was observed, however. Doppler echocardiography depicted mild to moderate mitral regurgitation in the three cases. Transesophageal echo confirmed the clinical suspicion of papillary muscle rupture: total rupture of antero-lateral papillary muscle in one patient, as well as total and partial rupture of the postero-medial papillary muscle in the other two patients. Two patients were submitted to mitral valve replacement, and the surgical findings confirmed the transesophageal echo conclusions. One of them died in the immediate pos-operative period, whereas the other was discharged from the hospital and is doing well. The third patient died before operation. Differential diagnosis of acute mitral regurgitation due to papillary muscle dysfunction or rupture was not possible by left ventriculography or by transthoracic echo. Transesophageal echo was the only exam to clearly confirm papillary muscle rupture, as should be done promptly after clinical suspicion of this severe condition arises

[Rupture of the left ventricular free wall. A lethal entity that can be surgically treated with success]. / Ruptura da parede livre do ventrículo esquerdo. Uma entidade letal que pode ser tratada cirurgicamente com sucesso.

We present three patients with left ventricular free wall rupture post acute myocardial infarction, all three treated successfully through surgery. Two of them were submitted to streptokinase IV. In all cases the diagnosis were based on clinical and echocardiographic features. The authors conclude that the diagnostic suspicion can be done easily, the echocardiogram is very useful, and the surgical treatment may led to a good short- and long-term survival.

Ruptura da parede livre do ventrículo esquerdo: uma entidade letal que pode ser tratada cirurgicamente com sucesso / Left Ventricular Free Wall Rupture. A Deadly Entity that can be Successfully Treated Through Surgery

We present three patients with left ventricular free wall rupture post acute myocardial infarction, all three treated successfully through surgery. Two of them were submitted to streptokinase IV. In all cases the diagnosis were based on clinical and echocardiographic features. The authors conclude that the diagnostic suspicion can be done easily, the echocardiogram is very useful, and the surgical treatment may led to a good short- and long-term survival

[Post infarction ventricular septal defect. Echocardiographic analysis of patients treated with positive end-expiratory pressure]. / Comunicação interventricular após infarto do miocárdio. Análise ecocardiografica de pacientes submetidos a pressão expiratória final positiva.

Interventricular septal rupture is a life-threatening complication occurring in 0.5 to 1.0% of patients following acute myocardial infarction and often results in right and left ventricular failure. This study aimed at evaluating the echocardiographic effects of PEEP on right (RV) and left (LV) ventricular dimension in three patients who developed a postinfarction septal defect and in whom acute respiratory failure was a preterminal event. The effects of PEPP on the heart remain controversial. We observed in all three patients a sudden large increase in RV dimensions and hence, probably through ventricular interdependence, a proportional decrease in LV dimensions. The progressive leftward septal displacement with increasing levels of PEEP probably contributed to reduce LV compliance. We concluded that PEEP therapy in this group of patients had no proven beneficial effects and probably contributed to further RV dilatation and failure.

Comunicaçäo interventricular após infarto do miocárdio: análise ecocardiográfica de pacientes submetidos a pressäo expiratória final positiva / Ventricular septal defect following myocardial infarction ­ echocardiographic analysis of patients submitted to positive final expiratory pressure

Comunicaçäo interventricular (CIV) como complicaçäo do infarto agudo do miocárdio (IAM) ocorre em 0,5 a 1,0% dos pacientes e freqüentemente resulta em falência biventricular. Avaliamos os efeitos ecocardiográficos da pressäo expiratória final positiva (PEEP) sobre as dimensöes dos ventrículos direito (VD) e esquerdo (VE) em três pacientes que desenvolveram CIV pós-infarto, complicado com insuficiência respiratória aguda. Em todos os casos houve súbito aumento nas dimensöes do VD e, provavelmente através da interdependência ventricular, uma proporcional diminuiçäo nas dimensöes do VE. Concluímos que a terapia com PEEP neste grupo de pacientes näo teve efeito benéfico comprovado e provavelmente acentuou a dilataçäo ventricular direita

Interventricular septal rupture is a life-threatening complication occuring in 0,5 to 1,0% of patients following acute myocardial infarction and often results in right and left ventricular failure. This study aimed at evaluating the echocardiographic effects of PEEP on right (RV) and left (LV) ventricular dimension in three patients who developed a postinfarction septal defect and in whom acute respiratory failure was a preterminal event. The effects of PEPP on the heart remain controversial. We observed in all three patients a sudden large increase in RV dimensions and hence, probably through ventricular interdependence, a proportional decrease in LV dimensions. The progressive leftward septal displacement with increasing levels of PEEP probably contributed to reduce LV compliance. We concluded that PEEP therapy in this group of patients had no proven beneficial effects and probably contributed to further RV dilatation and failure

[Pseudoaneurysm of the left ventricle resected 20 years after acute myocardial infarction]. / Pseudoaneurisma do ventrículo esquerdo ressecado vinte anos após infarto agudo do miocárdio.

A 67 year-old-man suffered an uncomplicated myocardial infarction twenty years ago. By January 1990 an abnormal cardiac contour was noted on a chest radiography. Contrast ventriculography revealed a pseudoaneurysm of the left ventricle. The patient underwent open heart surgery and remains asymptomatic 12 months after surgery. This is the longest time interval between the myocardial infarction and successful surgery that has been reported.

Pseudoaneurisma do ventrículo esquerdo ressecado vinte anos após infarto agudo do miocárdio / Pseudoaneurysm of the left ventricle resected 20 years after acute myocardial infarction

Homem de 67 anos de idade, com história de infarto do miocárdio, evoluiu desde entäo assintomático e após 20 anos, durante avaliaçäo clínica de rotina, identificou-se, à radiografia de tórax, imagem paracardíaca calcificada em regiäo diafragmática esquerda. O estudo angiográfico mostrou pseudoaneurisma do ventrículo esquerdo, corrigido cirurgicamente. O longo intervalo de tempo entre o infarto do miocárdio e a correçäo cirúrgica do pseudoaneurisma parece-nos o maior, em relaçäo a casos publicados

[Aneurysm of left ventricle associated with post-infarction interventricular communication]. / Aneurisma de ventrículo esquerdo associado à comunicação interventricular pós-infarto.

The authors report two cases of left ventricular aneurysm associated with post-infarction ventricular septal rupture. This rare association, usually aggravated by high mortality, received successful surgical treatment.

Aneurisma de ventrículo esquerdo associado à comunicaçäo interventricular pós-infarto / Aneurysm of left ventricle associated with post-infarction interventricular communication

Dois homens sexagenários apresentaram aneurisma do ventrículo esquerdo associado a comunicaçäo interventricular (CIV), na evoluçäo de infarto do miocárdio anterior extenso e ínfero-anterior. Os pacientes foram submetidos com sucesso a aneurismectomia ventricular esquerda, a revascularizaçäo do miocárdio e a fechamento da CIV