A case of recent myocardial infarction with cardiac failure.
A 50-year-old hypertensive smoker presented with a typical angina of 2 days duration. An urgent ECG revealed extensive anterior wall myocardial infarction. In view of the delayed presentation, the patient was conservatively managed with heparin. In-hospital echocardiogram showed akinesia of entire left anterior descending artery (LAD) territory with severe left ventricular (LV) dysfunction. He was discharged with a plan for early coronary intervention. However, he presented a fortnight later with acute pulmonary oedema. General appraisal revealed a restless individual who was dyspnoeic and diaphoretic at rest. On clinical examination, the patient was in hypotension with features of biventricular failure. A 12-lead ECG showed QS pattern with persistent ST segment elevation in precordial leads. The chest radiograph demonstrated features of pulmonary oedema, cardiomegaly and bilateral pleural effusion. Creatine Phosphokinase-MB (CPK-MB) was negative. A preliminary transthoracic echocardiography was done (figure 1 and see online supplementary video 1).



What is the most likely diagnosis based on the echocardiogram? LV pseudo-aneurysm with contained ruptureDissecting intramural haematoma of LV apexVentricular apical aneurysm with thrombusLV non-compaction with prominent ventricular trabaculations.
Department of Cardiology, Government Medical College, Kozhikode, Kerala, India.
Anishkumar
0000-0002-5589-9741
A
Nair
Department of Cardiology, Government Medical College, Kozhikode, Kerala, India.
Chakanalil Govindan
CG
Sajeev
Department of Cardiology, Government Medical College, Kozhikode, Kerala, India.
Kader
K
Muneer
D056988:Anterior Wall Myocardial Infarction / Q000150:complications* / Q000000981:diagnostic imaging / Q000503:physiopathology; D018618:Echocardiography, Doppler, Color; D006322:Heart Aneurysm / Q000000981:diagnostic imaging / Q000209:etiology* / Q000503:physiopathology / Q000601:surgery; D006333:Heart Failure / Q000000981:diagnostic imaging / Q000209:etiology* / Q000503:physiopathology; D006801:Humans; D008297:Male; D008875:Middle Aged; D011654:Pulmonary Edema / Q000209:etiology; D013927:Thrombosis / Q000000981:diagnostic imaging / Q000209:etiology* / Q000503:physiopathology / Q000601:surgery; D018487:Ventricular Dysfunction, Left / Q000000981:diagnostic imaging / Q000209:etiology* / Q000503:physiopathology; D016277:Ventricular Function, Left