Associazione Nazionale Medici Cardiologi Ospedalieri




Gattari Bianca Maria Padova(PD) – Azienda ospedaliera Padova | Betta Davide Vicenza(VI) – Ospedale Santorso | Gasparetto Nicola Treviso(TV) – Ospedale Ca’ Foncello

Case Report: A 44-year-old male was admitted to ICU for inferior STEMI in cardiogenic shock. The echocardiogram documented pericardial effusion in the right ventricle with initial signs of tamponade and the left ventricle with akinesia of the inferior-posterior wall and thinning of a small lateral portion, as from a pseudoaneurysm. Pericardiocentesis was performed with subsequent restoration of haemodynamic stability. The following emergency coronary angiography showed subocclusive stenosis of a thin postero-lateral branch (culprit lesion), critical stenosis at the origin of the anterior descending artery and occlusive stenosis of a developed diagonal branch. A CT scan documented a parietal breach in the middle of the left ventricle lateral wall with a pseudoaneurysm in close contiguity with the pericardium, in a setting compatible with contained cardiac rupture [Fig.1]. Hence, the patient underwent emergency cardiac surgery: a bovine pericardium patch was placed in the infarcted area, without complications. Later, percutaneous revascularisation on the left main-left anterior descending artery was performed.

A few months later the patient was asymptomatic at a cardiological check-up, nonetheless, the echocardiogram revealed aneurysmal dilatation in the middle of the left ventricle lateral wall [Fig.2]; heart CT scan and ventriculography confirmed a pseudo-aneurysmal formation at the site of previous patch placement. Cardiac surgery was unfeasible due to high intra-operative risk, therefore pseudoaneurysm percutaneous closure under radioscopic and transthoracic echocardiographic monitoring was performed, with good final echocardiographic result [Fig.3].

Discussion: Cardiac rupture is a relevant high-mortality complication of acute myocardial infarction which needs to be treated promptly. Early diagnosis plays a crucial role in changing the patient ‘s prognosis and is made possible by clinical, echocardiographic, haemodynamic and radiological criteria. The effectiveness of different treatment modalities is still controversial. In the presented case a surgical approach was preferred under emergency settings, while a less invasive percutaneous approach was chosen in the following and more stable situation.