Two- and three-dimensional transesophageal echocardiographic diagnosis of intramyocardial dissecting hematoma after myocardial infarction

A giant left ventricular pseudo-pseudoaneurysm following myocardial infarction

The ventricular pseudo-pseudoaneurysm is extremely scarce and potentially lethal because of acute hemopericardium and cardiac tamponade when a resultant complete tear occurs. Pseudo-pseudoaneurysms, which are formed by incomplete rupture of the myocardium, are usually small and limited to the thickness of the cardiac wall. We reported an uncommon case of a giant left ventricular pseudo-pseudoaneurysm, which was initially suspected by transthoracic echocardiography as a pseudoaneurysm.

Cardiovascular magnetic resonance and echocardiographic findings of a large thrombosed intramyocardial dissecting hematoma: a case report and a brief review of literature

Intramyocardial dissecting hematoma (IMDH) is an uncommon fatal complication after acute myocardial infarction. It is usually under identified. Transthoracic echocardiography is the first-line modality that can detect IMDH. Cardiac magnetic resonance could confirm the diagnosis. In this paper, we reported a unique partially thrombosed large left ventricle IMDH that mimics thrombosed true aneurysm aiming to highlight the supporting diagnostic transthoracic echocardiography and cardiac magnetic resonance criteria of IMDH.

Early Spontaneous Remission of Intramyocardial Dissecting Hematoma

Intramyocardial dissecting hematoma is a rare but potentially fatal complication of myocardial infarction. The decision to adopt a surgical or conservative strategy may depend on the clinical and hemodynamic stability of patients. Regardless, the precise and temporal assessment of the structure of hematoma is imperative. We herein report the first case of a patient with early spontaneous remission of intramyocardial dissecting hematoma successfully managed by a conservative approach with multimodality imaging.

[Spontaneous hematoma of the atrial wall]

The clinical signs of heart masses tend to be nonspecific, generally depending more on their repercussions on heart function caused by their location rather than on their type. Imaging techniques make it possible to limit the differential diagnosis of heart masses based on their location, morphology, and characteristics of echogenicity, density, or intensity, depending on the technique used to study them. We present the case of a woman with squeezing mid chest pain irradiating to her shoulder and positive cardiac markers in whom a left atrial mass was identified at echocardiography. This finding was confirmed at chest CT. The signs at chest CT were compatible with a mural hematoma and this diagnosis was confirmed after intraoperative biopsy.

Subepicardial aneurysm: echocardiographic evaluation and evolution

Subepicardial aneurysms (SEA) are an infrequent and serious form of subacute cardiac rupture complicating myocardial infarction. An early diagnosis and surgical repair may be life saving. SEA comprise an abrupt interruption of the myocardium, with a narrow neck and thin wall containing only the epicardium. It may progress to fatal cardiorrhexis. We describe the echocardiographic evolution of this type of cardiac rupture and the contribution of contrast-enhanced echocardiography. A possible pathophysiological mechanism is proposed.

Interventricular septum hematoma during cineventriculography

Background

Intraseptal hematoma and subsequent myocardial infarction due to accidental contrast agent deposition complicating diagnostic cineventriculography is a previously undescribed complication of angiography.

Case presentation

A 61 year old man was admitted at intensive care unit because of unstable angina pectoris 1 hour after coronary angiography. Transthoracic contrast echocardiography showed a non-perfused area in the middle of interventricular septum with an increase of thickening up to 26 mm. Review of cineventriculography revealed contrast enhancement in the interventricular septum after contrast medium injection and a dislocation of the pigtail catheter tip. Follow up by echocardiography and MRI showed, that intramural hematoma has resolved after 6 weeks. After 8 weeks successful stent implantation in LAD was performed and after 6 month the patient had a normal LV-function without ischemic signs or septal thickening demonstrated by stressechocardiography.

Conclusion

A safe and mobile position of the pigtail catheter during ventriculography in the middle of the LV cavity should be ensured to avoid this potentially life-threatening complication. For assessment and absolute measurement of intramural hematoma contrast-enhanced echocardiography is more feasible than MRI and makes interchangeable results.

Does Implantation of Sonomicrometry Crystals Alter Regional Cardiac Muscle Function?

BACKGROUND

Sonomicrometry is a gold standard in experimental studies on myocardial motion. However, limited information exists regarding mechanical and biochemical changes produced by sonomicrometry crystal (SC) insertion into the myocardial wall.

METHODS

In 10 open-chest pigs, we implanted SCs into the inner half of apical anterior and midposterior regions. Longitudinal strains (systolic lengthening, end-systolic, peak shortening, and postsystolic shortening strains) and strain rate (SR) measurements (peak systolic ejection and early and late diastolic SRs) were obtained by Doppler SR echocardiography along with troponin I levels measured from peripheral blood before and after SC insertion.

RESULTS

SR and strain parameters did not change significantly after SC implantation. Troponin I levels increased significantly from less than 0.010 to 0.129 +/- 0.138 microg/L (P < .005) after SC implantation.

CONCLUSIONS

Our study demonstrates that despite biochemical evidence of myocardial injury, carefully implanted SCs do not alter systolic or diastolic regional myocardial function assessed by Doppler echocardiography.

Traumatic Intramyocardial Left Ventricular Dissection: A Case Report

In this report, we present an unusual case of a patient who sustained and survived an intramyocardial dissecting hematoma with subacute ventricular rupture complicating a motor vehicle accident. In conclusion, we report on the diagnosis, management, and prior literature of this highly unusual and often lethal condition.

Long-term Follow-up of Intramyocardial Dissecting Hematomas Complicating Acute Myocardial Infarction

Intramyocardial dissecting hematoma is a form of subacute cardiac rupture complicating acute myocardial infarction. Initially contained within the myocardial wall, the hematoma may expand, rupture into adjacent structures, or spontaneously resolve. However, long-term follow-up is unknown because clinical and serial imaging data are lacking. The purpose of this study was to characterize the early and late myocardial wall changes after transmural myocardial infarction using serial ultrasound examinations of the infarct-related segments. Clinical, electrocardiographic, and echocardiographic features of 8 patients (7 men, mean age 59 years) who presented with acute myocardial infarction and echocardiographically documented intramyocardial dissecting hematoma were analyzed. All patients had precordial echocardiography and 6 underwent transesophageal echocardiography. Differentiating hematoma from trabeculations, thrombus, or pseudoaneurysm was done with contrast and color flow Doppler. Seven patients presented with S-T elevation in V1 to V4, and in 3 the elevation extended to V5, V6, I, and aVL. One patient presented with S-T elevation in II, III, aVF, V3R, and V4R. The most striking feature was persistent S-T elevation of more than 72 hours in all patients. Hematoma consisted of a cysticlike, echolucent cavity variable in size, adjacent to severely hypokinetic or dyskinetic infarct-related segments. Hematoma acoustic characteristics depended on time of evolution. Two patients underwent elective revascularization and the rest were medically treated. Two patients died and 6 were alive at the mean follow-up of 12 months. In conclusion, persistent S-T elevation is an important clue in suggesting intramyocardial dissecting hematoma, which is confirmed by its unique ultrasound appearance. Serial echocardiography is useful in determining its evolving nature, and may guide outcome.

Risk factors, echocardiographic patterns, and outcomes in patients with acute ventricular septal rupture during myocardial infarction

Ventricular septal rupture (VSR), which can complicate an acute myocardial infarction (MI), carries a high mortality rate. Because precordial and transesophageal echocardiography can identify the type of rupture and assess right ventricular (RV) function at the patient's bedside, we examined the prognostic significance of echocardiographic patterns in postinfarct VSR by postulating that complex rupture and RV involvement carry a worse prognosis. Seventeen patients (10 men; mean age 66 years) who had confirmed postinfarct VSR underwent precordial and transesophageal echocardiography followed by coronary angiography. Serial 12-lead and right precordial leads were also available. Type of septal rupture was classified as simple or complex based on autopsy-proved echocardiographic criteria. Three patients had inferior wall MI and 14 had anterior wall MI. ST-segment elevation persisted >72 hours in all 3 patients who had inferior wall MI and in 12 who had anterior wall MI. Segmental wall motion abnormalities helped in detecting the left ventricular entry site, and use of unconventional views superimposed with color flow Doppler provided the RV exit site. RV function was better appreciated with transesophageal echocardiography. Two patients who had inferior wall MI and 7 who had anterior wall MI had complex ruptures. All 3 patients who had inferior wall MI and 7 who had anterior wall MI had electrocardiographic and echocardiographic evidence of RV involvement. Mortality rate was higher in patients who had complex rupture (78% vs 38%, p <0.001) and in those who had RV extension (71% vs 29%, p <0.001). In conclusion, persistent ST elevation is a common finding in patients who have postinfarct VSR. Complex VSR and RV involvement are significant determinants of clinical outcome.

Left atrial hematoma complicating inferior myocardial infarction

Intramyocardial dissecting hematoma after myocardial infarction is a rare condition. Previous reports have documented that these hematomas form almost exclusively in the myocardium adjacent to the culprit coronary lesion. We report a case of coexistent intramyocardial dissecting hematoma and ventricular rupture that arose as a consequence of a distal right coronary artery occlusion. Unusually, there was a very long dissection plane, which crossed the atrioventricular groove, with the hematoma manifesting on the opposite side of the heart (left atrium) to the infarcted myocardium (inferior wall).

[Conservative management of a post infarction intramyocardial dissecting hematoma]

Intramyocardial dissecting hematoma is an infrequent complication of subacute myocardial infarction. Pathological findings consist of a cavity filled with blood, the outer wall of which is the myocardium and pericardium and the inner wall, which faces the ventricular cavity, is part of the myocardium and endocardium. There is scarce information on the subject and the management of these patients continues to be debated. However, there is a certain preference for surgical repair of the defect. Cases in which conservative treatment is a therapeutic option have been reported. We report the case of a patient with an intramyocardial dissecting hematoma after acute anterolateral myocardial infarction who was treated conservatively and achieved a satisfactory outcome in the intermediate-to-long term period.