Cardiovascular Disease Fellow HCA Orange Park, Orange Park, FL HCA Orange Park Jacksonville, Florida, United States
Background: Catastrophic complications after myocardial infarction (MI) include ventricular septal defect, papillary muscle or free wall rupture (FWR). Incidence of FWR is 1-4% of the time and occurs between 24 hours to 3 days post-MI. Patients present with chest pain and hemodynamic collapse. Risk factors include use of corticosteroids or NSAIDs.
Methods: A 70-year-old male with HTN, HLD, Tobacco Use presents with angina ~ 2-3 days. EKG showed ST Elevation II, III, AVF w/ lateral reciprocal changes. Patient was hypotensive on arrival with a BP of 89/53 and was urgently taken for catheterization. In the lab, hemodynamics demonstrated severely reduced cardiac index with a Cardiac Power Output (CPO) of 0.31 [ < 0.6 indicative of high in-hospital mortality] consistent with severe cardiogenic shock and Pulmonary Artery Pulsatility Index (PAPI) of 0.69 [ < 0.9 indicative of RV failure and in-hospital mortality]. Coronary angiography demonstrated culprit vessel as right coronary artery occlusion. Percutaneous LVAD was placed to provide mechanical circulatory support. Patient unfortunately had cardiac arrest, and stat TTE showed a pericardial effusion from free wall rupture (Figure 1). Home medication revealed patient recently started on prednisone.
Outcome: While incidence of FWR is known, there are no guidelines for early detection. In the case above, patient came in with chest pain ~ 2 days and was hemodynamically unstable. Free wall rupture was detected in the catheterization lab on TTE as clinical status declined. Clinicians ought to have higher index of suspicion in late presentation of MI and be conscientious of risk factors (i.e. steroids, NSAIDs) predisposing to mechanical complications. This case presentation proposes that for late presentation of MI, defined as symptoms > 24 hours, stat TTE should be done to assess for any mechanical complications. Guidelines exist to direct management; however, instructions are still needed to ensure timely detection of FWR.
