“Wheresoever you go, go with all your heart” Confucius

Introduction

Left ventricular free wall rupture is a known complication of myocardial infarction [ ₁ , ₂ ]. It is often fatal because of late diagnosis or complicated emergency surgical procedure, despite improved diagnostic techniques [ ₃ , ₄ ]. We describe a rare case of self-repair of a ventricular wall rupture following left circumflex artery acute occlusion with pathological findings never described before [ ₅ ].

Case Report

A 71-years-old man, EHM, had an acute, intense episode of chest pain on August the 3 ^rd , 2005 in another Country. Three days later he went to the Hospital, where a diagnosis of lateral myocardial infarction was made. On August 10, coronary angiography showed the occlusion of left circumflex artery, 50% stenosis on left anterior descending (LAD) artery and mild atherosclerosis of right coronary artery. The patient had also an echocardiographic assessment and was discharged from the Hospital with the diagnosis of: “Pseudoaneurysm of the posterior wall of the left ventricle and left circumflex artery occlusion”. He was a previous smoker, without any other risk factors for coronary artery disease and was affected by bronchial asthma treated with inhaled bronchodilators for ten years. Due to NYHA class II persistent dyspnea, he was scheduled for an echocardiographic control in our Hospital on September 29, during his stay with some relatives. This control showed a posterior pseudoaneurysm (50x50 mm) refilled by a small hole in the ventricle below the plane of mitral valve (Video 1) and a huge haematoma surrounding, as a crescent, the whole left ventricle (Fig. 1). There were no signs of cardiac tamponade, this lesion did not interest the right heart, but left ventricular wall motion was very impaired by the haematoma (Video 1). There was a grade 2 mitral regurgitation. We immediately admitted the patient and repeated the coronary angiography, which showed a more severe lesion on LAD. Surgical findings were peculiar: pericardial sac appeared under extreme tension (Fig. 2, A); opening the pericardial sac with the aid of femoro-femoral extracorporeal circulation did not cause bleeding: the whole left ventricle was surrounded by a thick-capsulated, wide, crescent-like haematoma, acting like a monoventricular constrictive pericarditis (Fig. 2, B, C); this haematoma was removed (Video 2); a thin-walled pseudoaneurysm was found at its very posterior bottom, causing pulsatile bleeding; then aorta was cross-clamped and a 4-mm wide, circular, smooth-edged hole in the postero-basal wall of the left ventricle was sutured by three interrupted, pledgeted, 4.0 prolene stitches (Fig. 2, D); the pseudoaneurysm wall was overlapped over this suture line; LAD was grafted with the left internal thoracic artery.

Figure 1

Figure 1: Frame of transthoracic echocardiogram showing the posterior pseudoaneurysm and the crescent-like haematoma surrounding the whole left ventricle.

Figure 2

Figure 2: Surgical steps: the pericardial sac under tension (A); the organized haematoma opened (B) and its empty capsula (C); the hole in the posterior wall with a small tube inside the left ventricle and the closing stitches (D). Note the thin, white pseudoaneurysm walls.

Postoperative course was uneventful. MR was grade 1. The patient was discharged on October 10. At 3-month follow-up he is in NYHA class I, with normal left ventricular function, trivial mitral regurgitation and no pericardial effusion.

Video 1: Transthoracic echocardiogram showing the impaired left ventricular function and slow-motion Color Doppler imaging of the flow in the pseudoaneurysm: note that the left ventricle is distorted and compressed by the haematoma.

Video 2: Intraoperative video showing the free left ventricle and the empty, thick capsula of the haematoma. Note that there is no bleeding from inside the capsula.

Correspondence to

Marco Cirillo, MD Poliambulanza Foundation Hospital Via Leonida Bissolati 57 25125 - BRESCIA - Italy Tel.: +39 030 351 5531 Fax: +39 030 351 5244 E-mail: cirillo-marco@poliambulanza.it