Unusual presentations of cardiac rupture during COVID-19 pandemic.

The Covid-19 pandemia has many other undesirable consequences apart of virus infection. Less people is hospitalized due to acute coronary syndrome and the delay to seek medical attention has increased. Patients with ST segment elevation myocardial infarction arrive at the hospital too late to be timely treated and we have recently seen mechanical complications that were more frequent in the past decades before the use of reperfusion strategies. In this report we describe the presentation, evolution and detailed imaging evaluation of two patients with unusual presentations of cardiac rupture: left ventricular pseudoaneurysm and left ventricular intramyocardial dissecting hematoma.

Left ventricular pseudoaneurysm associated with systemic lupus erythematosus.

Systemic lupus erythematosus (SLE) is associated with several cardiac manifestations but, to our knowledge, there have been no previously published reports on left ventricular (LV) pseudoaneurysm in this disease. We describe a case of a 30-year-old woman with SLE who presented with a disease flare (acute and subacute cutaneous lupus, pericarditis, fever, leukopenia) associated with heart failure syndrome. The patient was diagnosed with a large LV pseudoaneurysm and a bovine pericardium patch closure was performed. Coronary arteries were angiographically normal, and cardiac magnetic resonance imaging did not exhibit detectable myocardial fibrosis or infarction. Trauma, previous cardiac surgery, Chagas disease, and antiphospholipid syndrome were excluded. Histopathology of the pericardium revealed lymphocytic arteriolitis raising the possibility of an autoimmune-mediated mechanism for this complication. The unequivocal concomitant diagnosis of lupus flare, the exclusion of other causes of pseudoaneurysm and the histopathological finding of arteriolitis in this patient reinforces the hypothesis of lupus-mediated lesion.

Post-myocardial infarction left ventricular pseudoaneurysm diagnosed incidentally by echocardiography.

A 54-year-old male developed a left ventricular pseudoaneurysm (Ps) along the lateral wall of the left ventricle (LV), which was diagnosed incidentally by two-dimensional transthoracic echocardiography (2DTTE) 6 months after an acute myocardial infarction. Color flow imaging (CFI) showed blood flow from the LV into the aneurysmal cavity and invasive coronary angiography revealed sub-occlusion of the circumflex artery. A complementary study using cardiovascular magnetic resonance (CMR) confirmed a dilated left ventricle with depressed ejection fraction, thin dyskinetic anterolateral and inferolateral walls, a Ps adjacent to the lateral wall of the LV contained by the pericardium and blood passing in and out through a small defect in the LV mid-anterolateral wall. Late gadolinium-enhanced imaging demonstrated transmural myocardial infarction in the lateral wall and delayed enhancement of the pericardium, which formed the walls of the Ps. A conservative approach was adopted in this case, optimizing the patient's heart failure medications, including cardioselective beta-blocker agents, angiotensin-converting enzyme inhibitors, spironolactone and chronic anticoagulation therapy because of a high risk of ischemic stroke in these patients. At the 13-month follow-up, the patient remained stable with New York Heart Association class II heart failure. In conclusion, 2DTTE and CFI seem to be suitable initial methods for diagnosing Ps of the LV, but CMR is an excellent complementary method for characterizing further this cardiac entity. Furthermore, the long-term outcome of patients with Ps of the LV who are treated medically appears to be relatively benign. LEARNING POINTS: Left ventricular pseudoaneurysms are uncommon but severe complications of acute myocardial infarction.Transthoracic two-dimensional echocardiography and CFI are suitable non-invasive diagnostic methods for diagnosing left ventricular pseudoaneurysms.Cardiac magnetic resonance is an excellent complementary method, as it offers additional information for further characterization of this cardiac complication.Despite the fact that surgery is the treatment of choice to avoid a risk of fatal rupture, the long-term outcome of patients with left ventricular pseudoaneurysm who are treated medically appears to be relatively benign.