CONGRESS ABSTRACT

A 67-year-old woman was admitted to emergency room of a spoke hospital for chest pain which has been going on for two days. On electrocardiogram sub-acute anterior STEMI and Q waves in anterior leads. On coronarography: sub-occlusion on the mild tract of interventricular anterior artery, the other vessels were free from significant stenosis. A drug eluted stent was implanted. After percutaneous coronary intervention (PCI) the patient was admitted to our ICU mild-symptomatic for angina; on echocardiogram ejection fraction 35%, hyperkinesia of basal segment, akinesia of mid and periapical segment, aneurysm of the apex; right sections non dilatated with normal systolic performance; no pericardial effusion; estimated pulmonary systolic arterial pressure 30 mmHg; no significant valvular heart disease After six hour of hospitalization multiparametric monitor showed a sudden increment of heart rate; the patient was still symptomatic for chest pain. On electrocardiogram sinus tachycardia at FC 110 bpm, no new change of ST-T segment; systolic arterial pressure 110/70 mmHg; SaO2 98% with 2 l/min oxygen therapy. On clinical auscultation an apical heart murmur 3/6 Levine was present. The echocardiogram showed rupture of inferior part of distal interventricular septum with significant left to right ventricular shunt and moderate tricuspid regurgitation. After 30 minutes from the diagnosis the patient developed cardiogenic shock and acute respiratory failure and high degree of psychomotor agitation. To stabilize the patient orotracheal intubation was performed and pharmacological support to the circulation was started with dobutamine and norepinephrine. The patient was transferred to cardiac surgery department, where an arteriovenous ECMO was positioned. After six days of clinical observation, a surgical closure of the interventricular septum rupture was performed by patch implantation. The post-operative course was regular. The development of a mechanical complication should be suspected in case of persistence or new onset of chest pain in a patient who was previously hemodynamically stable. On clinical examination we can see the development of acute heart failure with a new heart murmur on cardiac auscultation. The diagnosis is performed with echocardiogram. Pharmacological and mechanical support to the circulation must be promptly placed in case of heart failure and the patient must be evaluated for percutaneous or surgical reparation of mechanical complication.