Patient Information
The patient was a 62-year- old man who was presented to the emergency department of Rasool Akram Hospital with symptoms of chest pain and epigastric discomfort that had begun 2 days prior to admission (PTA). The patient's past medical history was unremarkable, but he had a history of long-term smoking (30 pack-years). in physical examination, the patient was sitting upright with mild respiratory distress and moaning in pain. he was afebrile. The patients pulse rate, blood pressure and respiratory rate were 103 beats/minute (in regular rhythm), 80/50 mmHg, and 28/minute, respectively. jugular venous pressure was distended up to 6 cm. Heart sounds were regular, with an S3 gallop without any obvious rub or murmur. The results of the respiratory examination showed a decrease in bilateral breathing sounds. There was not any remarkable abnormality in gross examinations of the abdomen and nervous system. Initial electrocardiogram (ECG) showed sinus rhythm with HR of 105 bpm with ST segment elevation up to 3 mm in leads V2 to V5 and I and aVL, as well as ST segment depression in leads II, III and aVF (Figure 1).
Based on the above findings, with the diagnosis of acute MI, the patient was transferred to the CATH LAB for coronary angiography and primary PCI through the radial approach [3]. Coronary angiography showed involvement of two main coronary arteries including significant thrombotic stenosis in the middle part of the left anterior descending artery (LAD) along with total thrombotic occlusion in the first diagonal artery in the ostial part (figure 2).
The right coronary artery (RCA) also had two significant stenosis at the proximal and midportion. Based on studies supporting culprit-only revascularization versus multivessel revascularization, we decided to approach the LAD and diagonal but not the RCA. [2]. Therefore, coronary angioplasty was performed on LAD and diagonal artery with two drug eluting stents. Angioplasty was successful with restoration of acceptable flow according to thrombolysis in myocardial infarction (TIMI) 3 flow in infarcted artery (figure 3).
Because of persistent hypotension (systolic blood pressure 80 mmHg), echocardiography was performed to investigate possible mechanical complications of MI. The test results disclosed severe hypokinesis of the anterior and lateral wall. There was a 2-cm diameter echo-dense structure within the pericardial space, which was consistent with thrombus or hematoma (figure 4). RA and RV diastolic collapse was evident in several echocardiographic views. In addition, Echo revealed tissue defect at apical wall, which was related to ventricular free wall rupture. These findings were consistent with pericardial tamponade.
During echocardiography, continuous expansion of the hematoma in the pericardial space was evident, and at the same time, the patient had a change in mental status, confusion, shortness of breath, and diaphoresis. Therefore, the blood pressure was measured again, and the systolic blood pressure was 60 mmHg. Based on these observations and the diagnosis of free wall rupture, immediate supportive care including intravenous fluid injection with normal saline and inotropic agent with norepinephrine was started. And at the same time we consulted a heart surgeon. Despite supportive care, the patient's condition worsened and he was threatened with arrest.
Therapeutic Intervention
Therefore, considering the fact that it takes at least 1 to 2 hours for the surgical team to arrive and start the operation, and the patient's condition is critical, we decided to do something for him. So, the patient was returned back to the CATH LAB and successful pericardiocentesis was performed under fluoroscopy guidance (figure 5). After drainage of 100 cc pericardial effusion, the blood pressure (BP) started to rise and reached 100/70 in a minute, hemodynamic situation improved and mental status restored.
After that, the patient underwent emergency heart surgery. He underwent complete cardiopulmonary bypass, all blood material and thrombus inside the pericardial sac was drained (figure 6) and the infarct area was seen in the anterior wall of the left ventricle. A 6 mm long ventricular tear was found in the infarcted myocardium. A large Dacron patch was used to cover the infarcted area along with a 1 cm border around the healthy myocardium (figure 7).
The surgery was successful and the patient tolerated the surgery well. He had no complications during the rest of his hospital stay and was discharged after a successful rehabilitation period.
Follow-up and outcomes
One month after discharge, the patient was visited, he did not complain of chest pain or shortness of breath. Vital signs and physical examination were good. Follow-up echocardiography showed a 35% left ventricular ejection fraction, mild left ventricular enlargement, mild mitral regurgitation, and minimal pericardial effusion without any evidence of tamponade.