Double rupture of interventricular septum and free wall of the left ventricle, as a mechanical complication of acute myocardial infarction: a case report

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Abstract

Cardiac ruptures following acute myocardial infarction include rupture of the left ventricle free-wall, ventricular septal defects, and papillary muscle rupture. Double myocardial rupture is a rare complication of acute myocardial infarction (0.3 %) and the report of such cases is exclusively limited to a small series of autopsy studies.

Case presentation
In this report we present the unusual case of a 70-year-old woman with acute anteroseptal myocardial infarction, which was complicated by a combined rupture of the interventricular septum near the apex, and the free wall of the left ventricle with concomitant formation of a pseudoaneurysm. The double myocardial rupture was accidentally discovered 10 days later with echocardiography, when the patient, complaining only of mild exertional dyspnea, was hospitalized for a scheduled coronary angiography. The patient underwent successful surgical correction of the double myocardial rupture along with by-pass grafting.

Conclusion
This report highlights the importance of comprehensive noninvasive predischarge diagnostic evaluation of all postinfarct patients, since serious and potentially life-threatening complications might have not been suspected on clinical grounds.

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Introduction
Cardiac ruptures are serious and life-threatening mechanical complications of acute myocardial infarction (AMI). Types of rupture include left ventricle (LV) free-wall rupture (FWR), ventricular septal defect (VSD), and papillary muscle rupture (PMR). Double myocardial rupture (DMR) is defined as the coexistence of two of the above-mentioned forms of rupture. It complicates approximately 0.3% of AMI with the most frequent combination being FWR and VSD [1]. Small autopsy series report that DMR is seen in 13% of patients with FWR and in approximately 16% of patients with VSD [1]. The contribution of 2-D echocardiography and color Doppler in the early diagnosis of these lesions is well established [2]. Since DMR carries a high mortality, surgical correction, even in advanced age, constitutes the treatment of choice [3].

We present the case of a female patient whose recent AMI was complicated by a combination of VSD and FWR of the LV with formation of a pseudoaneurysm, which were successfully surgically corrected. This case is interesting due to the scarcity of such reports and the authors wish to emphasize both the contribution of echocardiography in identifying the above complications and the favorable outcome of our surgically treated patient, despite the seriousness of this complication and its relatively late diagnosis.

Case presentation
A 70-year-old-female, with a history of diabetes, arterial hypertension and mild chronic renal failure, fifteen days before her admission to our Department, had been admitted to another hospital, because of substernal squeezing pain of ten hours duration and an electrocardiogram compatible with acute anteroseptal myocardial infarction (ST-segment elevation in leads V1 to V4). Moreover, an echocardiographic study on admission was reported to show regional wall motion abnormalities in the territory of distribution of the left anterior descending coronary artery (LAD). In the absence of contraindications, she was administered fibrinolysis with Tenekteplase, which was considered successful using the current clinical and electrocardiographic criteria. On hospital day 5, the patient had an episode of hypotension, which was treated with infusion of normal saline but no further investigation due to its short duration and her relatively prompt recovery. On the 9th post-infarct day, the patient was discharged with the recommendation for follow-up coronary angiography.

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