Intraprocedural left ventricular free wall rupture diagnosed by left ventriculogram in a patient with infero-posterior myocardial infarction and severe aortic stenosis.
Left ventricular wall rupture remains a major lethal complication of acute myocardial infarction and hypertension is a well-known predisposing factor of cardiac rupture after myocardial infarction.



An 87-year-old man was admitted to our hospital, diagnosed as acute myocardial infarction (AMI). The echocardiogram showed 0.67-cm(2) aortic valve, consistent with severe aortic stenosis (AS). A coronary angiography showed a chronic occlusion of the proximal left circumflex artery and a 99 % stenosis and thrombus in the mid right coronary artery. During percutaneous angioplasty of the latter, transient hypotension and bradycardia developed at the time of balloon inflation, and low doses of noradrenaline and etilefrine were intravenously administered as needed. The patient suddenly lost consciousness and developed electro-mechanical dissociation. Cardio-pulmonary resuscitation followed by insertion of an intra-aortic balloon pump (IABP) and percutaneous cardiopulmonary support were initiated. The echocardiogram revealed moderate pericardial effusion, though the site of free wall rupture was not distinctly visible. A left ventriculogram clearly showed an infero-posterior apical wall rupture. Surgical treatment was withheld because of the interim development of brain death.



In this patient, who presented with severe AS, the administration of catecholamine to stabilize the blood pressure probably increased the intraventricular pressures considerably despite apparently normal measurements of the central aortic pressure. IABP, temporary pacemaker, or both are recommended instead of intravenous catecholamines for patients with AMI complicated with significant AS to stabilize hemodynamic function during angioplasty.
Department of Cardiology, Hokkaido Cardiovascular Hospital, 1-30, West 13, South 27, Chuou-ku, Sapporo, 064-8622, Japan. takaokonishi0915@gmail.com.|Department of Translational Pathology, Hokkaido University School of Medicine, Sapporo, Japan. takaokonishi0915@gmail.com.
Takao
T
Konishi
Department of Cardiology, Hokkaido Cardiovascular Hospital, 1-30, West 13, South 27, Chuou-ku, Sapporo, 064-8622, Japan.
Naohiro
N
Funayama
Department of Cardiology, Hokkaido Cardiovascular Hospital, 1-30, West 13, South 27, Chuou-ku, Sapporo, 064-8622, Japan.
Tadashi
T
Yamamoto
Department of Translational Pathology, Hokkaido University School of Medicine, Sapporo, Japan.
Hiroshi
H
Nishihara
Department of Cardiology, Hokkaido Cardiovascular Hospital, 1-30, West 13, South 27, Chuou-ku, Sapporo, 064-8622, Japan.
Daisuke
D
Hotta
Department of Cardiology, Hokkaido Cardiovascular Hospital, 1-30, West 13, South 27, Chuou-ku, Sapporo, 064-8622, Japan.
Kenjiro
K
Kikuchi
Department of Cardiovascular Surgery, Hokkaido Cardiovascular Hospital, Sapporo, Japan.
Hideo
H
Yokoyama
Department of Cardiovascular Surgery, Hokkaido Cardiovascular Hospital, Sapporo, Japan.
Katsumi
K
Ohori
D000369:Aged, 80 and over; D015906:Angioplasty, Balloon, Coronary; D001024:Aortic Valve Stenosis / Q000175:diagnosis* / Q000209:etiology; D017023:Coronary Angiography; D017809:Fatal Outcome; D015637:Gated Blood-Pool Imaging / Q000379:methods*; D006341:Heart Rupture / Q000000981:diagnostic imaging* / Q000209:etiology; D006801:Humans; D007431:Intraoperative Complications; D008297:Male; D009203:Myocardial Infarction / Q000150:complications* / Q000175:diagnosis / Q000601:surgery
Acute myocardial infarction; Angioplasty; Aortic stenosis; Catecholamine; Intra-aortic balloon pump; Left ventricular wall rupture