CONGRESS ABSTRACT

An 34-year-old man presented to the emergency department of our hospital with palpitations and presyncope. He was a smoker but had no others known cardiovascular risk factors. At admission, his electrocardiogram (ECG) showed sustained monomorphic ventricular tachycardia (VT) at a rate of 187 beats per minute. The VT was successfully treated with synchronized direct current cardioversion. The ECG in sinus rhythm showed Qs from V1 to V6 with ventricular repolarization anomalies in the same site suspicious for previous anterior necrosis. A transthoracic echocardiogram revealed akinetic apex, akinesia of middle segments of the interventricular septum, anterior and lateral walls, Left Ventricular (LV) ejection fraction of 30% and a large apical mass suspicious for LV thrombus. The patient was admitted to the coronary care unit and taken to the Cath lab that showed total left anterior descending mid-segment occlusion. Due to the chronicity of the condition, the patient was recommended to optimal medical therapy. Suspecting LV thrombus, the patient began treatment with unfractionated heparin i.v. and subsequently imbricate therapy with enoxaparin s.c. and warfarin. Additionally, the patient underwent subcutaneous implantable cardioverter defibrillator (S-ICD) implantation for secondary prevention of sudden cardiac death. At echocardiographic follow-up one week after discharge, the apical mass remained unchanged despite warfarin therapy with INR at target. For this reason, the patient was recommended to perform a Cardiovascular magnetic resonance (CMR). Three months after S-ICD implantation, a CMR was performed which showed transmural areas of late gadolinium enhancement involving all apical segments and middle segments of the interventricular septum which allowed the diagnosis of a large intramyocardial dissecting hematoma (IDH) of left ventricle. IDH is a rare complication of ST-elevation myocardial infarction (STEMI), it is an unusual form of subacute cardiac rupture and could be fatal. It usually consists of a cavity or channels within the myocardium. Its prognosis varies according to its location, but generally apical IDH have more favorable outcome with a higher likelihood of spontaneous retraction. We report this case because the IDH is a diagnostic challenge and it represents an extremely rare and poorly described event in the literature.