Leaking Heart: Ticking Time Bomb!
A 72-year old male with hypertension presented to emergency room with light headedness and hypotension. Initial blood pressure was 80/50 mmHg and heart rate was 70 beats/minute. Electrocardiogram revealed evidence of tall R waves in lead V1-2 []. Troponin I level was 11.9 ng/mL. An emergent echocardiogram revealed a large pericardial effusion with fibrinous material []. Patient denied any other complaints including chest pain or dyspnea and wished to be discharged home. He did mention that he had an episode of chest pain 1 week earlier that resolved spontaneously and he did not seek medical care. Based on electrocardiogram and echocardiogram findings, we suspected patient suffered a posterior myocardial infarction which was complicated by contained free wall rupture and pericardial effusion. Based on the high index of suspicion, patient was taken for emergent coronary angiography which revealed 100% circumflex occlusion and right heart catheterization was consistent with tamponade physiology. Left ventriculogram showed an ejection fraction of 40% with staining of postero-basal wall suggestive of possible cardiac rupture. Patient underwent emergent percutaneous coronary intervention to the left circumflex along with placement of an intraaortic balloon pump, and emergent pericardiocentesis with removal of 50cc of hemorrhagic fluid. This led to hemodynamic stabilization. Limited pericardiocentesis was done to prevent dislodgement of the clot which may be tamponading the ruptured site. Patient was then taken to operating room immediately. Intraoperative a large amount of hemorrhagic fluid with clot was removed. The infarcted posterior myocardium showed necrosis and hemorrhage with multiple puncture sites leaking/oozing blood. A large patch was created with combination of Bio Glue and patient's own pericardium. This was glued onto the posterior wall and then sewn with a running 5-0 Prolene reinforced with multiple pledgeted 5-0 Prolene circumferentially around the posterior wall in the area of the circumflex distribution with care taken to avoid the circumflex artery itself. This appeared to completely stop all the bleeding. Post-operatively, patient did well in the intensive care unit for three days. However, on the fourth day patient suddenly developed pulseless electrical activity due to repeat free wall rupture and died.