Images in cardiology: Intramyocardial dissection after subacute anterior wall myocardial infarction

Subacute Left Ventricular Free Wall Rupture after Delayed STEMI Presentation During the COVID-19 Pandemic

The coronavirus disease-2019 (COVID-19) pandemic is causing delayed ST-segment elevation myocardial infarction (STEMI) presentations associated with now unusual postinfarction complications. We describe a delayed (5-day) STEMI presentation because the patient feared contracting COVID-19 in the hospital. The patient experienced an extensive anterolateral STEMI complicated by subacute left ventricular free wall rupture that required a rapid surgical repair. (Level of Difficulty: Intermediate.)

A rare complication of acute myocardial infarction: Intra-myocardial dissecting hematoma

A rare and unusual form of myocardial rupture that can complicate acute myocardial infarction is intra-myocardial dissecting hematoma (IDH). Reports in the literature describing this entity are limited to case reports or series. The diagnosis prior to the advent of noninvasive imaging was at autopsy. We present a case of IDH occurring after acute anterior wall myocardial infarction that terminated fatally preceded by a hemodynamically unstable incessant ventricular tachycardia.

Echocardiography and Cardiac Rupture: Is Contrast Extravasation an Indication for Surgery?

Contrast echocardiography demonstrating microbubbles in the pericardial space has often been cited as evidence of ventricular rupture requiring emergent surgical intervention. We report a case where no myocardial perforation was found during post-myocardial infarction surgery despite prior echocardiographic evidence of contrast extravasation into the pericardial effusion. Clinical decision making requires balancing imaging evidence with clinical circumstances to determine the optimal timing for surgical intervention.

Covered rupture of the free left ventricular wall or "only" thrombus in a true aneurysm?

Complications after acute myocardial infarction (AMI) concerning the wall structure may be a true aneurysm, intramyocardial dissection, rupture of the free left ventricular wall covered by pericardium or formation of pseudoaneurysm. Differentiation between these complications of AMI may be difficult as shown by the following case report but is of paramount importance because of the different management.

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.