PMC3426227_01
(a) Surface electrocardiogram in sinus rhythm with QS waves in III and aVF, QS waves in V1-V6 elevation of ST segment of <0.1 mv in V3 to V6, atrioventricular first degree block and asymmetric inversion of T wave in I and aVL. (b) Troponin I level evolution during hospitalization.
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fig1
Electrocardiogram showed q wave in III, aVF, asymmetric wave inversion in leads I and aVL and elevation of ST segment of <0.1 mv in V3 to V6, (Figure 1(a)). Elevation of cardiac troponin I level to 78 ng/mL was found normal: <0.04 ng/mL (Figure 1(b)).
(a) Transthoracic two-dimensional and color Doppler echocardiogram in four-chamber view, showing the left ventricular apical aneurysm (LVAn), the site of rupture (arrow) and the pseudonaeurysm formation (curved arrow). (b) Zoom in lateral wall rupture with color Doppler.
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fig2
A 2D echo (SONOS 5500, Philips Medical Systems, Bothell, Washington, USA) performed at the bedside in the emergency room showed the site of LVFWR, the blood flow from the LV to the pericardial space and diastolic flow from the pericardial space to the LV with hemopericardium contained by echo-dense pericardial adhesions, and an LV apical aneurysm (Figure 2).
In (a) an important thickening of the pericardium containing the hemopericardium is seen and in (b) the cardiac hybrid CTA image shows a significative obstruction of circumflex artery in its middle segment (white arrow).
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fig3
A cardiac CT was done to assess the coronary anatomy and the pericardium, which showed a total occlusion of circumflex artery in its middle segment (Figure 3) and an important thickening of the pericardium at the LV lateral wall.
(a) The myocardial perfusion imaging with TC-99 M Sestamibi SPECT at rest and stress with dipyridamole demonstrated left ventricular lateral wall and apical transmural myocardial infarction without peri-infarction myocardial ischemia. (b) Bull's eye plots were created by automated quantitative analysis software, representing the stress and rest data.
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fig4
TC-99 M Sestamibi SPECT at rest and stress with dipyridamole demonstrated LV lateral wall and apical transmural MI without peri-infarction myocardial ischemia (Figure 4). The serial echo studies and the MRI did not show any progression of the LVP (Figure 5).
(a) Four-chamber view cardiac MR cine SSFP shows an apical aneurysm (LV An) and a lateral left ventricular pseudoaneurysm (red arrows). Apical transmural hyperenhancement is also seen in (b).
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fig5
TC-99 M Sestamibi SPECT at rest and stress with dipyridamole demonstrated LV lateral wall and apical transmural MI without peri-infarction myocardial ischemia (Figure 4). The serial echo studies and the MRI did not show any progression of the LVP (Figure 5).
Two-dimensional (a), and color Doppler four-chamber view (b) images showing an apical aneurysm (LVAn) and lateral pseudoaneurysm formation (red arrow) with shunt from the left ventricle to the pericardial space. RV-right ventricle, RA-right atrium, Pseudoan-pseudoaneurysm.
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During a follow-up period of 24 months the patient continues to be in NYHA functional class II, and the 2D and 3D echo studies performed with a IE33 Philips Medical Systems confirmed a circular lateral wall rupture (Figures 6 and 7, and see supplementary material, movie clip Figures 6 and 7 available online at doi: 10.1155/2012/728602).
Real time 3D internal (a) and external (b) echocardiographic views of the left ventricular free wall rupture, which has a circular geometry.
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fig7
During a follow-up period of 24 months the patient continues to be in NYHA functional class II, and the 2D and 3D echo studies performed with a IE33 Philips Medical Systems confirmed a circular lateral wall rupture (Figures 6 and 7, and see supplementary material, movie clip Figures 6 and 7 available online at doi: 10.1155/2012/728602).