J Cardiol 2007 Feb; 49 2 : 97 102 Blow Out 1 Survivor of Blow Out Type of Free Wall Rupture: Multislice Computed Tomographic Detection of Myocardial Rupture in a Case of Small Myocardial Infarction Atsushi Shigeomi Satoko Hiroyuki Hiroyuki Yoshifumi Takashi HOSHINO, MD YOKOYA, MD ENOMOTO, MD KAWAHITO, MD KURATA, MD NAKAHARA, MD NAKAMURA, MD Abstract A 73-year-old man was admitted to the emergency room because of shock and loss of consciousness. Electrocardiography and echocardiography revealed myocardial infarction of the inferoposterior wall and cardiac tamponade. However, laboratory data showed mild inflammation without elevation of any cardiac enzymes. Under percutaneous cardiopulmonary support, coronary angiography showed stenosis of only a small posterior descending branch of the right coronary artery. Multislice computed tomography provided a definite diagnosis of free wall rupture of the left ventricle, clearly showing the tear of the inferior wall. After surgical repair and rehabilitation, he returned to a normal life. Small inferior wall infarction rarely causes the blow out type of left ventricular free wall rupture. Multislice computed tomography is a fast and noninvasive tool for the detection of ventricular rupture as well as acute dissection of ascending aorta, both of which may result in cardiac tamponade and may not be visualized by echocardiography. J Cardiol 2007 Feb ; 49 2 : 97 102 Key Words Myocardial infarction, treatment free wall rupture Computed tomography multislice Cardiac tamponade blow out multislice computed tomography : MSCT blow out MSCT 73 : 520 3046 2 4 1 Department of Cardiology, Saiseikai Shiga Hospital, Shiga Address for correspondence : HOSHINO A, MD, Department of Cardiology, Saiseikai Shiga Hospital, Ohashi 2 4 1, Ritto, Shiga 520 3046; E-mail : a-hoshi@mvg.biglobe.ne.jp Manuscript received October 11, 2006; accepted November 2, 2006 97
98 Fig. 1 Twelve-lead electrocardiogram on admission showing abnormal Q wave and ST elevation in, and avf, and ST depression in and avl Fig. 2 Transthoracic two-dimensional echocardiograms on admission from the epigastric window showing massive echogenic pericardial effusion arrows A: Long-axis view. B : Short-axis view. : : : : 20 : : 2006 6 24 27 28 8 20 : 152cm 46kg 86/41mmHg 92/min SpO 2 100% O 2 10l : a F ST Q a L ST Fig. 1 Fig. 2 WBC 10,500/ l CRP 8.95 mg/dl : J Cardiol 2007 Feb; 49 2 : 97 102
Blow Out 99 40mmHg 99% Fig. 3 MSCT Fig. 4 6 24 Fig. 3 Coronary angiogram on admission showing 99% stenosis in the posterior descending artery arrow Fig. 5 magnetic resonance imaging : MRI Fig. 6 blow out 2 7% 10% 2 1 7 8 12 CK 13 CK-MB 150IU/l 14 Matoh 15 Suzuki 16 oozing Nishizaki 17 blow out blow out Fig. 4 Multislice computed tomograms on admission in the long-axis view A and short-axis view B Myocardial tear in the inferior wall arrows and massive pericardial effusion. J Cardiol 2007 Feb; 49 2 : 97 102
100 Q ST 99% Fig. 5 Transthoracic two-dimensional echocardiogram from the apical view after surgical repair showing the myocardial tear arrrow MSCT 8 MRI 8,15,18,19 MRI oozing MSCT MSCT MSCT MSCT Fig. 6 Delayed enhancement magnetic resonance images after surgical repair in the short-axis view A and long-axis view B Transmural enhancement can be clearly seen in a very narrow range of the inferior wall, including the myocardial tear arrows. J Cardiol 2007 Feb; 49 2 : 97 102
Blow Out 101 blow out MSCT 73 99% blow out J Cardiol 2007 Feb; 49 2 :97 102 1 Mundth E : Rupture of the heart complicating myocardial infarction. Circulation 1972; 46 : 427 429 2 Feneley MP, Chang VP, O Rourke MF : Myocardial rupture after acute myocardial infarction : Ten year review. Br Heart J 1983; 49 :550 556 3 Dellborg M, Held P, Swedberg K, Vedin A : Rupture of the myocardium: Occurrence and risk factors. Br Heart J 1985; 54 :11 16 4 Reddy SG, Roberts WC: Frequency of rupture of the left ventricular free wall or ventricular septum among necropsy cases of fatal acute myocardial infarction since introduction of coronary care units. Am J Cardiol 1989; 63: 906 911 5 Becker RC, Gore JM, Lambrew C, Weaver WD, Rubison RM, French WJ, Tiefenbrunn AJ, Bowlby LJ, Rogers WJ : A composite view of cardiac rupture in the United States National Registry of Myocardial Infarction. J Am Coll Cardiol 1996; 27 : 1321 1326 6 Sugiura T, Nagahama Y, Nakamura S, Kudo Y, Yamasaki F, Iwasaka T: Left ventricular free wall rupture after reperfusion therapy for acute myocardial infarction. Am J Cardiol 2003; 92 :282 284 7 Slater J, Brown RJ, Antonelli TA, Menon V, Boland J, Col J, Dzavik V, Greenberg M, Menegus M, Connery C, Hochman JS : Cardiogenic shock due to cardiac free-wall rupture or tamponade after acute myocardial infarction: A report from the SHOCK Trial Registry: Should we emergently revascularize occluded coronaries for cardiogenic shock? J Am Coll Cardiol 2000; 36 3 Suppl A : 1117 1122 8 Birnbaum Y, Chamoun AJ, Anzuini A, Lick SD, Ahmad M, Uretsky BF : Ventricular free wall rupture following acute myocardial infarction. Coron Artery Dis 2003; 14 : 463 470 9 Antman EM : ST-elevation myocardial infarction. in Management in Heart Disease : A Textbook of Cardiovascular Medicine ed by Braunwald E, Zipes DP, Libby P, Bonow RO, 7th Ed. WB Saunders, Philadelphia, 2005; pp 1203 1207 10 Pollak H, Diez W, Spiel R, Enenkel W, Mlczoch J : Early diagnosis of subacute free wall rupture complicating acute myocardial infarction. Eur Heart J 1993; 14 :640 648 11 Batts KP, Ackermann DM, Edwards WD : Postinfarction rupture of the left ventricular free wall : Clinicopathologic correlates in 100 consecutive autopsy case. Hum Pathol 1990; 21 :530 535 12 Figueras J, Curos A, Cortadellas J, Sans M, Soler-Soler J : Relevance of electrocardiographic findings, heart failure, and infarct site in assessing risk and timing of left ventricular free wall rupture during acute myocardial infarction. Am J Cardiol 1995 ; 76: 543 547 13 Ikeda N, Yasu T, Kubo N, Hirahara T, Sugawara Y, Kobayashi N, Hashimoto S, Tsuruya Y, Fujii M, Saito M: Effect of reperfusion therapy on cardiac rupture after myocardial infarction in Japanese. Circ J 2004 ; 68 :422 426 14 Pohjola-Sintonen S, Muller JE, Stone PH, Willich SN, Antman EM, Davis VG, Parker CB, Braunwald E : Ventricular septal and free wall rupture complicating acute myocardial infarction : Experience in the Multicenter Investigation of Limitation of Infarct Size. Am Heart J 1989; 117: 809 818 15 Matoh F, Hayashi H, Takeda H, Satoh H, Katoh H, Urushida T, Shiraki K, Asai M, Sakahara H, Takehara Y : Usefulness of delayed enhancement magnetic resonance imaging for detecting cardiac rupture caused by small myocardial infarction in a case of cardiac tamponade. Circ J 2005; 69: 1556 1559 16 Suzuki N, Motoyoshi K, Kozuma K, Suzuki M, Yokoyama N, Yamamoto Y, Suzuki S, Kaminaga T, Ishikawa S, Ueda K, Isshiki T: Cardiac rupture caused by myocardial infarc- J Cardiol 2007 Feb; 49 2 : 97 102
102 tion in the diagonal branch area : Evaluation by cardiac multislice computed tomography: A case report. J Cardiol 2005; 46 :71 76 in Jpn with Eng abstr 17 Nishizaki K, Seki T, Fujii A, Nishida Y, Funabiki M, Morikawa Y : Sutureless patch repair for small blowout rupture of the left ventricle after myocardial infarction. Jpn J Thorac Cardiovasc Surg 2004; 52 : 268 271 18 Zoni A, Arisi A, Corradi D, Ardissino D: Images in cardiovascular medicine : Magnetic resonance imaging of impending left ventricular rupture after acute myocardial infarction. Circulation 2003; 108: 498 499 19 Lesser JR, Johnson K, Lindberg JL, Reed J, Tadavarthy SM, Virmani R, Schwartz RS : Images in cardiovascular medicine : Myocardial rupture, microvascular obstruction, and infarct expansion : Elucidation by cardiac magnetic resonance. Circulation 2003 ; 108: 116 117 J Cardiol 2007 Feb; 49 2 : 97 102