Figure 3 - uploaded by Zhaoying Wen
Content may be subject to copyright.
Echocardiographic images from Case 6 showing LV apical myocardial dissection post -MI. A, B. The first echocardiogram after 10 days of MI, the dissection area (*) was stretched in systole A. and collapsed in diastole B. The crescent thrombus was noticed at the upper part of the dissection area. C. The same images 24 hours later showing soft clots filling the dissection cavity. D. Same images 18 hours further later showing spontaneously absorbed cavity, filled with organized thrombus. LV = left ventricle, MI = myocardial infarction.
Source publication
Objectives:
Intramyocardial dissecting hematoma (IDH) after acute myocardial infarction (MI) is a rare form of subacute cardiac rupture and hence management uncertainties. The objective of this study was to describe the clinical course of a small series of IDH patients and to review the available evidence for managing similar cases.
Methods:
Eig...
Context in source publication
Context 1
... cases 4, 5, 6, and 7 had LV anterior septal and apical infarction, but the dissection involved mainly the septal region in cases 4 and 5 (Fig. 2), with significant interventricular communication at the apical level, across the septum to mid RV region. In cases 6 and 7, the dissection involved mainly the LV apex, with no detectable flow across (Fig. 3). In view of the stable hemody- namic status of these patients, cases 4 and 5 underwent elective coronary artery bypass sur- gery (CABG) and repair of the septal defect, but cases 6 and 7 were treated medically, and their apical neo-cavitations formed a thrombus and spontaneously regressed. Case 8 had apical sep- tal MI with small ...
Similar publications
Background:
Cardiac rupture often occurs after myocardial infarction or chest trauma with a high mortality rate. However, left ventricular rupture caused by radiofrequency catheter ablation (RFCA) is extremely rare.
Methods:
We describe a case of a 61-year-old male who survived from left ventricular rupture caused by a RFCA procedure for frequen...
Background:
Improvements in revascularisation, including pharmacological, catheter-based and surgical, have resulted in improved outcomes for patients with acute myocardial infarction (AMI), leading to decreased frequency of mechanical complications. Improvements in both techniques and technology have permitted select patients to be managed with a...
Symmetrical peripheral gangrene is an ischemic necrosis simultaneously involving the distal portions of two or more extremities without any proximal arterial obstruction or vasculitis. It may occur as a result of a large number of infectious and non-infectious causes. A few cases of symmetrical peripheral gangrene associated with cardiac disease ha...
Background
Left ventricular rupture is the most feared complication in mitral valve surgery. Despite its low incidence, mortality rates can reach up to 75%. It usually presents on the operating room with a dissecting haematoma followed by massive bleeding after discontinuing cardiopulmomary bypass. However, cardiac rupture may be contained by adhe...
Ventricular free wall rupture is a fatal mechanical complication of acute myocardial infarction. In some cases it can be represented as subacute clinic and may not cause death in a few minutes. Acute pseudo-aneurysms are extremely unstable and bound to fatal rupture. Herein we report a male patient who suffered dyspnea and mild chest pain, 4 weeks...
Citations
... Its treatment is not clearly defined, particularly in subacute/chronic cases with nondefined clinical course injuries such as IDH. 2 Surgery has been proposed as the gold-standard treatment for post-myocardial infarction rupture because of the risk of complete tearing of the ventricular wall. 1 Nevertheless, given the high surgical risk in such cases, both percutaneous and medical approaches have been postulated as feasible and safe second options depending on the type of lesion. 1,3 When the IDH presents with entry tear thrombosis, this can seal the cavity and prevent increasing pressure on the damaged wall, reducing the potential risk of rupture and facilitating blood stasis (Supplemental Figure 2). ...
Intramyocardial dissecting hematoma (IDH), in the setting of an acute coronary syndrome, is a rare type of cardiac rupture. However, the best treatment for IDH in each clinical scenario is not clearly defined. We present a case in which the best approach for IDH and its final outcome are discussed.
... 3 The mortality rate in patients with intramyocardial haematoma is up to 90%, especially among those with right ventricular dissection. 4 A large dissecting intramyocardial haematoma as a nightmare complication following arterial switch operation has not been reported so far. There are no evidence-based recommendations for the management of this rare complication in either adult or in the paediatric population. ...
... The majority of reported intramyocardial dissecting haematomas were associated with myocardial infarction in adult patients. 2,4,5 In our patient, this complication was probably iatrogenic, caused by the compression of the right ventricle by the sternal retractor during atrial septum closure. ...
Herein we present the right ventricular dissection and describe its successful management after arterial switch operation in a full-term male neonate. There are no evidence-based recommendations for the management of this rare complication. Our management included veno-arterial extracorporeal membrane oxygenation placement and delayed surgical evacuation of the dissecting haematoma with beneficial outcomes.
... All intramyocardial space-occupying cavitating lesions following myocardial infarction can be termed DMH. Following echocardiographic features of DMH have been described in the literature: [20,22,23] 1. Formation of neocavity with the echo-lucent center 2. The inner border should be mobile and endomyocardial 3. The outer side of neocavity should be lined by the myocardium 4. Changing echogenicity of a cavity with time, suggestive of blood in the cavity 5. Partial or complete absorption of a cavity 6. Continuity between dissecting hematoma and the ventricular cavity may occur 7. Doppler demonstration of color flow in the cavity may be possible [ Figure 26]. ...
Right ventricular myocardial infarction (RVMI) occurs in up to half of the patients of inferior wall myocardial infarction. RVMI results in edema and increased right ventricular (RV) mass, and hence, it should be possible to visualize microvascular obstruction as a manifestation of reperfusion injury. Reperfusion injury of the RV myocardium following primary percutaneous coronary intervention has been rarely reported. This report describes a patient with the left ventricular inferior and RVMI who showed echocardiographically detected reperfusion injury of the RV-free wall and left ventricular basal inferolateral wall and conformed by myocardial contrast perfusion study despite successful percutaneous revascularization of the right coronary artery.
... All intramyocardial space-occupying cavitating lesions following myocardial infarction can be termed DMH. Following echocardiographic features of DMH have been described in the literature: [20,22,23] 1. Formation of neocavity with the echo-lucent center 2. The inner border should be mobile and endomyocardial 3. The outer side of neocavity should be lined by the myocardium 4. Changing echogenicity of a cavity with time, suggestive of blood in the cavity 5. Partial or complete absorption of a cavity 6. Continuity between dissecting hematoma and the ventricular cavity may occur 7. Doppler demonstration of color flow in the cavity may be possible [ Figure 26]. ...
This report describes a 68-year-old female who, immediately after the primary percutaneous coronary intervention of the left anterior descending artery for acute anterior myocardial infarction, developed an apical aneurysm and a “neo-chamber” within the left ventricular cavity separated from the main cavity by a linear thick hyperechoic free-floating fenestrated membrane. This was an excoriated but perforated subendocardial spiral myocardial layer separated from the subepicardial layer due to ischemia and infarction. Multiple orifices on the inner surface were observed, possibly due to patchy necrosis. In addition, there was a large remote intramyocardial hematoma in the inferolateral wall of indeterminate pathogenesis.
... IDH is generally classified as complex hemorrhagic dissection, in which blood infi ltrates into the myocardial wall. [2] IDH is characterized by a serpiginous tract within the myocardium, which is also known as subepicardial aneurysm. The mechanisms of IDH are multifactorial and contribute to the rupture of intramyocardial vessels, diminished tensile strength of the infarcted myocardium, abrupt increases in perfusion pressure during the perfusion phase, or in rare cases, iatrogenesis. ...
... Diagnosis of IDH is based on the presence of 3 or more of the following signs: (1) the formation of at least 1 neocavitation within the tissue with an echolucent area, which expands during systole and shrinks during diastole; (2) thin and mobile endomyocardial border that surrounds the involved myocardial defect; (3) Doppler evidence of the continuity between dissecting hematoma and one of the ventricular cavities; (4) communication between the 2 ventricles; (5) partial or complete spontaneous retraction of the dissection flap; (6) presence of ventricular septal rupture, papillary muscle, or chordal rupture. 5 This may be surrounded by an extensive area of infarction of the involved coronary artery. We consider our case to be an IMD without hematoma as there was no visualization of clotted blood within the neocavity seen between the 2 myocardial layers on imaging or on gross surgical specimen. ...
• LV IMD is a rare complication of blunt chest trauma. • Associated papillary muscle avulsion led to severe MR. • Transthoracic echocardiography provides a rapid diagnosis of this rare entity. • Image sweeps of MV with TTE can help to fully visualize partial papillary ruptures.
... The dissection between the spiral myocardial fibres is formed by the influx of blood, creating neocavitation that is entirely contained within an integrated myocardial wall. 1 It occurs most commonly in the free wall of the left ventricle, the interventricular septum (IVS), and the free wall of the right ventricle. 2 This uncommon complication is usually detected by transthoracic echocardiography (TTE) and a definitive diagnosis is made by magnetic resonance imaging (MRI). Management of these patients is based on individual clinical judgment and can be conservative or surgical. ...
Background
Intramyocardial dissecting hematoma (IDH) is a rare and potentially life-threatening complication of acute coronary syndrome. So far only isolated case reports and case series have been published.
Case summary
We report the case of a late presenting myocardial infarction (MI) complicated by IDH of the ventricular septum, following a successful percutaneous coronary intervention (PCI). The clinically inapparent septal mass was discovered during the routine transthoracic echocardiography and the final diagnosis of hematoma was made by magnetic resonance imaging. The patient remained clinically stable, and septal mass on repeated echocardiography showed gradual regression.
Discussion
This report suggests that IDH can spontaneously resolve without surgical intervention. An urgent echocardiogram should be used to assess the vitality of the myocardial tissue, especially with late presenting MI with deep Q waves on the ECG strip. Conservative treatment in hemodynamically stable patients with IDH following MI and PCI is a feasible solution.
... As already mentioned, IDH is a rare complication either of myocardial ischemia or trauma. IDH may be considered a complex hemorrhagic dissection of ventricular wall as an uncommon type of cardiac rupture, whereas the simple transmural rupture could be labeled as simple tear [9]. The intramuscular bleeding may result from fragile intramuscular vessels in the infarction, from decreased tensile strength in the infarcted tissue or from rapid increase of intravascular pressure during reperfusion treatment [2]. ...
... The exact estimation of prognosis is difficult because of lack of data in small unrecognized IDHs [11]. In a big metaanalysis, there was no significant difference in mortality in patients undergoing surgical and conservative treatment [9]. Small IDHs confined to the apical segments are more likely to reabsorb spontaneously [3]. ...
Intramyocardial dissection or intramyocardial dissecting hematoma is uncommon complication either of myocardial infarction or severe thoracic injury. Intramyocardial dissecting hematoma is caused by intersecting bleeding between the layers of myocardial fibers. In contrast to cardiac rupture, the myocardial wall maintains its integrity. In this paper, we present a case of patient suffering with ischemic heart disease, reporting worsening chest pain and dyspnea 2 months after autovenous graft bypass surgery. The coronary angiography revealed severe stenosis of the autovenous graft, which was treated by stent implantation. Three hours after intervention, the patient showed signs of cardiogenic shock with clinical suspicion of heart tamponade because of ventricular wall rupture. The patient died despite the surgical drainage of the hematoma and blood transfusions. In the necropsy, the large intramyocardial dissecting hematoma in the very superficial layer of the left ventricular myocardium was found, accompanied with very small extent of necrotic myocardium in the neighborhood of the intramyocardial dissecting hematoma. The prevailing majority of the left ventricle thickness was vital. The lack of developed transmural infarction in our case leads us to hypothesis that the increased intravascular pressure during the reperfusion is the main contributor to the intramyocardial dissecting hematoma development, together with reduced biomechanical resistance of the capillaries affected by chronic ischemia.
... Presenta zonas de disrupción de tejido miocárdico y hemorragia, afectando con mayor frecuencia al SIV que a la pared libre. En el caso del SIV, la ruptura ocurre en diferentes planos 6 . En el 69% de los casos, se presentan en el contexto de un IAM inferior, siendo afectado en el 80% el SIV basal póstero-inferior. ...
... En el 69% de los casos, se presentan en el contexto de un IAM inferior, siendo afectado en el 80% el SIV basal póstero-inferior. En el 12% restante, hay una combinación de ambas [5][6][7] . Ocasionalmente, en la ruptura compleja también están comprometidos la pared libre y los músculos papilares. ...
... La ruptura cardíaca asociada a IAM inferior, generalmente, está asociada a un IAM del ventrículo derecho 8 . La disección hemorrágica está causada tanto por la ruptura de los vasos sanguíneos intramiocárdicos como por una disminución de la fuerza de tensión del miocardio infartado, esto genera un hematoma que va disecando las fibras miocárdicas espiraladas de la pared ocasionado por la presión intracavitaria, similar a lo que ocurre en un hematoma disecante de aorta 6,7 . Si la disección ocurre fuera de la pared, la neocavidad estará formada por pericardio y miocardio, mientras que si permanece dentro de la pared estará contenida por el miocardio y el endocardio. ...
... Histological examination of IMDH patients shows widely separated muscle bundles with blood in between, taking different forms and shapes, for example, large channels and lakes. 5,6 Echocardiographically, various investigators have diagnosed IMDH based on the presence of at least three of the following signs 5,6 : ...
... Clinical outcome of IMDH varies, sometimes it quickly evolves into a complete rupture with a need for urgent cardiac surgery, in others, it may take a slow course and even heals by itself. 6,7 Among the potential complications, the risk of ventricular tachyarrhythmia with sudden cardiac death is also an important consideration in patients who have IMDH. ...
Intramyocardial dissecting hematoma is an under-recognized complication after acute myocardial
infarction. Transthoracic echocardiography allows diagnosing intramyocardial hematoma at the bedside,
documenting its evolution and assessing the effects on left ventricular remodeling. Cardiac magnetic
resonance imaging provides complimentary information and is often required for differential diagnosis
of this condition. Treatment depends upon the rate of expansion of hematoma. Sometimes in stable
patients, hematoma regresses with the time and does not require any intervention whereas in other
cases, rapidly expanding hematoma with hemodynamic compromise will require urgent surgical
intervention.
