Anterior wall ST-elevation myocardial infarction complicated by a ruptured left ventricular aneurysm: a case report

¹Department of Cardiology, Ibn Rochd Hospital University, Casablanca, Morocco

^&Corresponding author
Yassine Ettagmouti, Department of Cardiology, Ibn Rochd Hospital University, Casablanca, Morocco

Introduction    

The mechanical complications of myocardial infarction (MI) are dreadful, and occur frequently following a transmural infarction. The increasing use of noninvasive techniques has allowed earlier recognition and better appreciation of left ventricular aneuvrysm (LVA) genesis and pathophysiology [1]. With the development of coronary angiography, angioplasty and coronary artery bypass surgery, the occurrence of post-infarction ventricular aneurysms has become rare. However, it should be well known to the clinician because of their severity with an inevitable death if rupture of aneurysm as our case demonstrates it. In this sense, we present an unusual case of LVA with a wall rupture, a complication that has become extremely rare due to the progress of fast and urgent revascularization.

Patient and observation     

Patient information: we report the case of a 63-year-old male, active smoker, with a history of diabetes mellitus and hypertension who was referred to our tertiary hospital for shortness of breath and worsening chest pain evolving for 3 days. The patient did not seek medical advice at the onset of his pain and was content with analgesic treatment. As his symptoms did not improve, the patient decided to consult until the third day of chest pain.

Clinical findings: the medical examination revealed a conscious patient with a blood pressure of 110/70 mmHg, respiratory rate of 27 breaths/min, Oxygen saturation of 96%, heart rate of 105 bpm, apyretic.

Timeline: day 0: onset of acute chest pain. Day 0-2: medical analgesic treatment of pain without specialist consultation. Day 3: consultation to the cardiology emergency room in front of the persistence of the pain, discovery of an aneurysm of the left ventricle. H74: hemodynamic instability with occurrence of a cardio respiratory arrest.

Diagnostic assessment: electrocardiography (EKG) presented a sinus rhythm of 99bpm, anterior Q waves with a persistent ST elevation (Figure 1). Further investigation consisted in realizing an echocardiography that revealed an apical aneurysmatic enlargement with a left ventricular contrast and a reduction of the ejection fraction of 34% (Figure 2). The lab work showed increased cardiac markers with an ultrasensitive troponin I at 38,000, with a moderate inflammatory syndrome with a CRP at 55 mg/l and a hyperleukocytosis at 13 950/mm³.

Therapeutic intervention and follow up and outcomes: a double antiplatelet and anticoagulation loading dose was administered: 600 mg aspirin and clopidogrel, 80 IU UFHDue to the persistence of chest pain, the patient was sent to the catheterization room, however, the evolution was marked by a hemodynamic instability which rapidly evolved into an unrecovered cardio-circulatory arrest in accordance with a rupture of the left ventricle. A detailed explanation of the delay in consultation and the repercussions was given to the family and the patients, as well as the poor prognosis generated.

Informed consent: written informed consent was obtained from the patients for publication of this case report and any accompanying images.

Discussion     

A pseudoaneurysm of the left ventricle is a paracardial blood cavity that forms when a rupture of the myocardium is contained by adherent pericardium or scar tissue. In contrast to a true aneurysm, which retains all of its elements [2,3]. Left ventricular pseudoaneurysm preferential location is in the posterior or inferior wall, while true wall aneurysms are preferably located in the anterior wall [4]. The etiological causes vary from congenital aneurysm to an acquired one: Ischemic, Infective, traumatic or idiopathic. The detection of a cavity in the left ventricle wall after a myocardial infarction (MI) is a diagnostic challenge, and it´s clinical presentation in wide. Patients often present with a symptomatology of chest pain, dyspnea, heart failure, cardiogenic shock or sudden death. Embolic phenomena or arrhythmias are rare. In 10% of cases, patients remain completely asymptomatic [5]. Currently, the literature review reveals that angiography, and more specifically ventriculography, allows a definitive diagnosis in 85% of cases with only 2% of false negatives. However, it remains an invasive technique [1]. It demonstrates a large, discrete area of dyskinesia (or akinesia), generally in the anteroseptal-apical walls. Occasionally, left ventriculography also may demonstrate mural thrombus.

Transthoracic ultrasound is a less invasive, less expensive, and readily available technique to make the diagnosis. It allows differentiating between a true and false type aneurysm by depicting a narrow neck compared to the size of the cavity. Color-flow echocardiographic imaging may identify abnormal flow within the aneurysm. This information may help identify a thrombus. Its limits remain the conditions in which it is performed, which are not always optimal, as well as its operator-dependent character. It is generally used as a first-line procedure, but is less sensitive [6,7]. Clinicians should keep in mind that a ventricular aneurysm can mimic a variety of clinical conditions: Angina pectoris, a left ventricular pseudoaneurysm, a ventricular wall rupture, a pericarditis or myocarditis, myocardial trauma, Takotsubo cardiomyopathy [8].

Despite adequate management, the prognosis of this condition is poor, with an estimated mortality of 30%. The first interventions of a ventricular aneurysm were described in 1944 by Beck [9], who performed an external reinforcement of the aneurysm wall with fascia lata. The first aneurysm repair by direct linear suture under extracorporeal circulation was described by Cooley et al. [10] in 1958. It was the work of Beck's team [9] and Jatene [11] on the importance of maintaining elliptical ventricular kinetics and geometry that led to the development of LV repair. The incidence of LV aneurysms is certainly lower nowadays thanks to the early reperfusion of infarcts (thrombolysis, angioplasty) and the use of converting enzyme inhibitors, which act respectively on the initial phase of aneurysm formation and late post-infarct remodeling of the LV. On the other hand, some authors do not recommend this surgery because of the lack of medium-term benefit [12], while others report an improvement in medium-term survival [13].

Conclusion     

This case shows a unique iconography of a giant apical aneurysm of the left ventricle, a complication rarely seen today with the advances in rapid revascularization of acute coronary syndromes. Through this case report, it is important to raise awareness of the fact that acute chest pain should not be trivialized and that a specialist should be consulted as a matter of urgency, since any delay in treatment has a negative impact on the patient's health.

Competing interests     

The authors declare no competing interests.

Authors' contributions     

Yassine Ettagmouti: writing paper. Khawla Chawki: study concept literature. Hajar Bendahou: interpretation and analysis. Rachida Habbal: interpretation and analysis. All the authors have read and agreed to the final manuscript.

Figures     

Figure 1: electrocardiography showing anterior Q waves with a persistent ST elevation

Figure 2: apical 4-cavity slice showing a large apical aneurysm of the left ventricle with spontaneous intraventricular contrast

References