Fatal Post-Infarction Late Left Ventricular Free Wall Rupture in the Era of COVID-19.

A 71-year-old woman without a cardiovascular history was transferred from a nearby hospital to our catheterization laboratory in cardiogenic shock on vasopressors following a very late presentation anterior ST-segment elevation myocardial infarction (STEMI) (Figure 1A ). She reported avoiding early medical care because of fear of acquiring coronavirus disease 2019 (COVID-19) in the hospital. She was experiencing prolonged episodes of chest pain on and off for 15 days prior to her acute syncopal presentation. Urgent coronary angiography demonstrated a proximal occlusion of the left anterior descending coronary artery (Figure 1B, white arrow) in a right-dominant unobstructed coronary artery system. Subsequent ventriculography showed poor left ventricular (LV) systolic function with evidence of extravasated and clotted blood in the pericardium at the level of the apical wall (Figure 1C, black arrow) (Video 1 ). An immediate diagnosis of a late post–myocardial infarction (MI) apical LV free wall rupture was made, and urgent alerting of the cardiothoracic surgical team was performed for external patching of the cardiac rupture. Percutaneous revascularization to the culprit left anterior descending coronary artery occlusion was done with implantation of 1 zotarolimus-eluting stent (3.0 × 26 mm) with restoration of TIMI (Thrombolysis In Myocardial Infarction) flow grade 3 (Figure 1D). Focused pre-operative transthoracic echocardiography confirmed the severe LV systolic dysfunction, with the presence of coagulated blood in the pericardium (Figure 1E, lined red arrow) due to cardiac rupture (Figure 1F, red arrow) (Videos 2 , 3 ). Unfortunately, while awaiting transfer to the operating room, the patient deteriorated and died.

Figure 1

Post-Infarction Left Ventricular Free Wall Rupture

(A) Twelve-lead electrocardiogram showing Q waves and ST-segment elevation in leads V1 to V6, I, and aVL compatible with a late presentation of an anterior ST-segment elevation myocardial infarction. (B) Coronary angiogram showing complete occlusion of the proximal left anterior descending coronary artery (white arrow) and TIMI (Thrombolysis In Myocardial Infarction) flow grade 0. (C) Left ventriculography in the 30° right anterior oblique view showing an apical left ventricular free wall rupture. Note the extravasation of contrast in the pericardial space (black arrow) causing the double density of the pericardium (lined black arrow). (D) Successful percutaneous coronary intervention with implantation of 1 zotarolimus-eluting stent (just after the origin of the first diagonal branch) and restoration of TIMI flow grade 3. (E) Focused transthoracic echocardiography (subcostal view) showing presence of coagulum (lined red arrow) in the pericardial space with evidence of apical free wall rupture (red arrow) in (F) (5-chamber view). See Videos 1, 2, and 3.

Online Video 1

Online Video 2

Online Video 3

Focused transthoracic echocardiography showing severe left ventricular systolic dysfunction and the cardiac rupture.

Focused transthoracic echocardiography showing the cardiac rupture.

Left ventriculography showing poor left ventricular systolic function with evidence of extravasated and clotted blood in the pericardium at the level of the apical wall.

Admissions for acute MI were significantly reduced during the COVID-19 pandemic worldwide, possibly because of the fear of contagion at the hospital, with a parallel increase in fatality and complication rates (1). Delayed revascularization in STEMI poses a significant challenge because of the reemergence of rare and often fatal mechanical MI-related complications, as in our patient.

LV free wall rupture occurs in approximately 1 in 13,000 patients (0.007%) and frequently results in death, with in-hospital mortality rates of 57% and 80% in large studies. It is more common in the anterior and lateral walls and is associated with old age, lack of collateral circulation, and ischemic preconditioning and presentation with first MI, as in our patient. The most frequent presentation is with syncope or pulseless electric activity and pericardial effusion; however, nearly half of deaths due to cardiac rupture occur as out-of-hospital sudden deaths (2,3).

Cardiac rupture must be ruled out in patients with STEMI presenting very late. Prompt recognition of this complication in the cardiac catheterization laboratory using ventriculography is necessary to allow immediate surgical alerting and operation. Even with early diagnosis, mortality remains extremely high. In the COVID-19 era, health care providers should continue educating patients to recognize life-threatening cardiovascular symptoms and seek timely care to avoid serious complications.