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Published on: June 11, 2019
LV Apical Rupture Complicating Acute Myocardial Infarction: The Role of CMR
Deirdre F Waterhouse1, Theodore M Murphy1, James McCarthy2
1Blackrock Clinic- Center for Cardiovascular Magnetic Resonance, Blackrock Clinic, Dublin, Ireland.
Insights
This case study highlights acute myocardial infarction with left anterior descending coronary artery occlusion, leading to ventricular rupture and apical thrombus. Multimodality imaging is crucial for diagnosing complex cardiac anatomy and guiding treatment.
Area of Science:
- Cardiology
- Cardiac Imaging
- Interventional Cardiology
Background:
- Acute myocardial infarction (MI) can lead to severe complications.
- Left ventricular (LV) rupture and apical thrombus formation are rare but life-threatening consequences of MI.
Purpose of the Study:
- To illustrate a case of acute myocardial infarction complicated by left anterior descending coronary artery occlusion, apical ventricular rupture, and apical thrombus.
- To emphasize the role of multimodality cardiac imaging in diagnosing and managing such complex cases.
Main Methods:
- Electrocardiogram (ECG)
- Transthoracic echocardiogram (TTE)
- Coronary angiography
- Cardiac magnetic resonance imaging (CMR)
Main Results:
- Coronary angiography revealed multivessel disease with ostial occlusion of the LAD.
- Echocardiography and CMR confirmed a large apical thrombus and LV aneurysm, indicative of contained rupture.
- CMR provided detailed 3D visualization of the cardiac abnormalities.
Conclusions:
- Complementary multimodality imaging (echocardiography and CMR) is essential for accurate delineation of unusual cardiac anatomy.
- TTE may miss large, apical LV thrombi.
- CMR aids surgeons in visualizing functional and morphological abnormalities to guide interventions, though optimal management of ventricular rupture remains debated.
Purpose:
This case illustrates an acute myocardial infarction with occlusion of the left anterior descending coronary artery complicated by apical ventricular rupture and apical thrombus.
Procedures:
An electrocardiogram, transthoracic echocardiogram (TTE), coronary angiography and cardiac magnetic resonance imaging (CMR) guided optimal management of the patient.
Findings:
Coronary angiography revealed multivessel disease with an ostial occlusion of the LAD. Echocardiography showed apical dilatation of the left ventricle with a large, echogenic mass at the apex. Contrast echocardiography confirmed the presence of a large apical thrombus, separated from the LV cavity by myocardium. A CMR showed a completed LAD infarct and a filling thrombus was noted in the aneurysmal apical region inferring a contained rupture of the LV apex.
Principle Conclusions:
Accurate and definitive delineation of unusual cardiac anatomy is best provided by complementary multimodality cardiac imaging, echocardiography and CMR. TTE can miss LV thrombi, particularly when they are large, aneurysmal and apical in nature. CMR provides the cardiac surgeon the ability to visualise in 3D the functional and morphological abnormalities, helping guide necessary intervention. Optimal management of patients with ventricular rupture remains controversial both in terms of timing and choice of intervention.
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